Journal of Personality Assessment

ISSN: 0022-3891 (Print) 1532-7752 (Online) Journal homepage: http://www.tandfonline.com/loi/hjpa20

Millon's Contributions to Preadolescent and

Adolescent Personality Assessment: Searching
Onward and Upward

Robert Tringone & Neil Bockian

To cite this article: Robert Tringone & Neil Bockian (2015) Millon's Contributions to
Preadolescent and Adolescent Personality Assessment: Searching Onward and Upward,
Journal of Personality Assessment, 97:6, 563-571, DOI: 10.1080/00223891.2015.1064438

To link to this article: http://dx.doi.org/10.1080/00223891.2015.1064438

Published online: 30 Jul 2015.

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 Journal of Personality Assessment, 97(6), 563–571, 2015
Copyright Ó Taylor & Francis Group, LLC
ISSN: 0022-3891 print / 1532-7752 online
DOI: 10.1080/00223891.2015.1064438

SPECIAL SECTION: Theodore Millon’s Legacy for Personality Theory and Assessment

Millon’s Contributions to Preadolescent and Adolescent Personality

Assessment: Searching Onward and Upward
ROBERT TRINGONE1 AND NEIL BOCKIAN2
1
Center for Counseling and Consultation, St. John’s University
2
Psychology Department, Adler University
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Theodore Millon was one of the most influential personality theorists of the 20th century. His theory was originally rooted in biosocial learning
models and later reconceptualized as an evolutionary model. This foundation of Millon’s work encompasses the entire life span. He had a genuine
concern for humankind, especially children. His theory encompasses a comprehensive understanding of the relationship among childhood
experiences, parenting styles, and recurring events throughout the life span in shaping the personality. Notable contributions to child and
adolescent assessment are the Millon Adolescent Personality Inventory (Millon, Green, & Meagher, 1982), the Millon Adolescent Clinical
Inventory (Millon, Millon, & Davis, 1993), and the Millon Pre-Adolescent Clinical Inventory (M–PACI; Millon, Tringone, Millon, & Grossman,
2005). Given Millon’s influence on the personality disorders section of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the
aforementioned instruments have personality constructs tied to familiar DSM categories, and among them, cover the age range of 9 to 18 years
old. His development of the Millon Inventories revolutionized personality assessment in the United States and abroad. Millon’s legacies will live
on through his works and through the respect and compassion he demonstrated toward others.

Theodore Millon was a scholar, theorist, teacher, innovator, entire life span, beginning with its earliest phases. He created
mentor, and leader in his professional life. He was a loving an elaborate and elegant theory for understanding personality
family man, kindhearted friend, and generous benefactor in spectra that extend from normal styles to disorders (Millon,
his personal life. He was a true Renaissance man, knowledge- 2011). It is an elaborate theory because it includes universal
able in diverse subjects such as physics, cosmology, mathe- guiding principles, fundamental neuropsychologically based
matics, architecture, art, literature, music, and languages. He stages of development, and a taxonomic classification system.
had an unquenchable thirst for knowledge, and in his intellec- These components are linked with a family of assessment
tual pursuits he emphasized the importance of an integrated instruments that have been developed to measure the personal-
approach to understanding world issues and individuals, an ity constructs identified by the theory and therapeutic interven-
approach that incorporated what we know from history, the tions designed to modify problematic patterns. These
sciences and the arts, the quantitative and the qualitative. He components were constructed into a framework he labeled
sought to understand the universe and humankind while clinical personology (Millon, 1990).
attending to so many who had the privilege to know him. This article provides an overview of Millon’s personality
Millon’s most recognizable work centers on his important theory and how personality styles are derived configurally and
contributions to the personality assessment field, starting with experientially. It next addresses how Millon changed the land-
the introduction of the Millon Clinical Multiaxial Inventory scape of personality assessment with each of his groundbreak-
(MCMI; Millon, 1977), and his advocacy for the multiaxial ing instruments. The adolescent and preadolescent measures
format of previous versions of the Diagnostic and Statistical that bear his name have provided clinicians with valuable
Manual of Mental Disorders (DSM–III [American Psychiatric insights into their young clients and have been the subject of
Association, 1980], DSM–III–R [American Psychiatric Asso- scores of research studies that have enlightened the interplay
ciation, 1987], and DSM–IV [American Psychiatric Associa- between personality and clinical syndromes. The synthesis of
tion, 1994]). In recent times, he had mused that his last name his wisdom, acumen, and foresight into a comprehensive sys-
had become an objective entity. “The Millon” was shorthand tem serves as a framework that can guide the next generation
for one of the many inventories that bear his name, much akin of researchers, scholars, and clinicians to a deeper understand-
to how evaluators often refer to “the Rorschach.” Although ing of personality.
these key contributions were adult focused, his theory, which
became the foundation of his life’s work, encompasses the
THEORETICAL BEGINNINGS
Received October 5, 2014; Revised April 29, 2015. In his first major text, Modern Psychopathology (Millon,
Address correspondence to Robert Tringone, Center for Counseling and 1969), Millon introduced his biosocial learning theory of
Consultation, St. John’s University, 8000 Utopia Parkway, Queens, NY personality patterns and clinical syndromes. The theory
11439; Email: tringonr@stjohns.edu represented a comprehensive and integrative alternative to

563
 564 TRINGONE AND BOCKIAN

other prominent theories at the time. He incorporated and orientation) in terms of investing considerable time and energy
expanded on illuminative ideas from his primary influen- nurturing few offspring.
ces—Gardner Murphy, Ernst Kris, and Kurt Goldstein— In the Millon system, these polarities are combined to
who stressed that patterns become gradually ingrained derive and explicate the essence of each personality style as a
through repeated experiences, that the person and environ- personality prototype. Additionally, they explain the central
ment mold one another, and that a holistic approach to the underlying and reciprocally reinforcing dynamics of each pat-
person is the most clinically sound one. A multitude of fac- tern. Four “core” personality styles are theoretically identified
tors influence personality development. Each person pos- as “interpersonally imbalanced.” For these personality styles,
sesses a distinctive set of biological predispositions, has his the central polarity is the self–other polarity in which there is
or her own unique developmental experiences, faces a wide a strong emphasis on one source of reinforcement at the
range of sociocultural influences, and must deal with what- expense of the other. Dependent types look to others for a
ever random events might occur in his or her life. Although sense of security and pain avoidance, whereas independent
we might have little to no control over some of these fac- types rely on themselves for similar needs. These types are
tors, it is generally accepted that parent–child interactions further divided into active and passive variants. The active
affect a child’s developing personality. Millon believed dependent types correspond to the histrionic personality with
that personality and, in turn, psychopathology, progresses its persistent seeking of stimulation and excitement as well as
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through a “developmental process in which intra-organismic its solicitous efforts to secure attention and affection from
and environmental forces display not only a reciprocity and multiple attachment figures, whereas passive dependent types
circularity of influence but an orderly and sequential conti- correspond to the dependent personality, which is well recog-
nuity throughout the life of the individual” (Millon, 1969, p. nized for its strong need to attach to a significant other for a
210). He formulated, in a systematic manner, what those sense of safety and security as well as its willingness to subor-
experiences might entail for each personality pattern recog- dinate its own desires to please someone else. The passive
nized in the current nomenclature and others that can be independent types in this system correspond to the narcissistic
derived according to his theory. personality. From the reinforcement perspective, this person-
ality has been continually and often unconditionally showered
with admiration and praise from others, which has led them to
believe they are special and, subsequently, develop a high
THEORY: PERSONALITY POLARITIES level of self-worth. As a result, they can feel content and
Millon’s personality theory (1969, 1981, 2011; Millon & secure just being themselves. The active independent types, in
Davis, 1996) is founded on three polarities: pleasure–pain, contrast, have typically had difficult upbringings and might
active–passive, and self–other. These polarities are configured have experienced the world as an uncaring, ungiving, and hos-
to conceptualize personality patterns that exist on a spectrum tile or even dangerous place. Others cannot be relied on and,
from normal to disorder. The model was originally formulated with a precarious sense of security, the antisocial personality
as a biosocial learning theory with an emphasis on reinforce- learns to take care of his or her own needs by whatever means
ment (Millon, 1969, 1981). Personality patterns were viewed necessary, even if it involves violating rules and the rights of
as learned strategies to secure positive reinforcement and min- others.
imize punishment. The pleasure–pain polarity represented Four other personality styles are labeled intrapsychically
the nature of the response elicited from others, which could conflicted. The ambivalent types experience an intense conflict
be positive (pleasure) or negative (pain). The active–passive within the self–other polarity over whether to look to self or to
polarity represented the behavior employed to maximize others as the source of reinforcement. The compulsive person-
rewards and minimize pain, and the self–other polarity repre- ality (passive ambivalent variant) attempts to resolve the con-
sented the source to which an individual turned for reinforce- flict through compliance and accommodation to others by
ment. Millon later reconceptualized his theory as an acting in responsible and conscientious ways as well as adher-
evolutionary model (Millon, 1990, 2011; Millon & Davis, ing to strict sets of rules that govern their behavior. The nega-
1996). At this level, the polarities represent life functions or tivistic personality (active ambivalent variant), on the other
divisions. For example, the pleasure–pain polarity represents hand, endures an invidious struggle that impacts virtually all
existence in terms of life enhancement (pleasure) versus life domains of life. Two discordant types, the sadistic (active var-
preservation (pain). The active–passive polarity represents life iant) and masochistic (passive variant) personalities, approach
forms in which the active polarity includes the animal king- life and relationships according to a reversal within the plea-
dom, and the passive polarity includes the plant kingdom. Of sure–pain polarity. The former personality derives pleasure
course, there are exceptions to each group, but the majority of from inflicting pain (fear, stress) and exerting power (control,
members of the animal kingdom are mobile and take action to dominance) over others in an assertive manner, whereas the
secure reinforcement or assure their existence, whereas the latter personality’s interactions and intimate relationships
majority of members of the plant kingdom are stationary, leave them feeling aggrieved.
must accommodate to what the environment offers them, and Detached types turn neither to self or others for positive
rely on the environment to provide reinforcement or suste- reinforcement. The avoidant personality is conceptualized as
nance to exist. The self–other polarity highlights the two pri- the active detached pattern. These personalities withdraw in a
mary reproductive strategies—self-focused (r-strategy—male self-protective manner to avoid pain, typically suffer from low
orientation) in terms of potentially having multiple partners self-esteem, and have limited coping resources. An imbalance
and a multitude of progeny, while assuming limited childrear- within the pleasure–pain polarity also exists given their
ing responsibilities, and other-focused (K-strategy—female propensity to anticipate pain and limited focus on pleasure.
 PREADOLESCENT AND ADOLESCENT PERSONALITY ASSESSMENT 565

The schizoid personality is conceptualized as the passive responses from their parents, especially those parents who are
detached type. These personalities seem to have a limited perceptive and well-attuned to their child’s needs. On the
capacity to experience either psychic pleasure or pain and pos- other hand, infants who have a restive disposition, who might
sess an intrinsically weak motivation to seek out rewards have trouble regulating their eating and sleep patterns, or who
through social contact with others. seem difficult to comfort could elicit very different responses.
Three more severe personality variants—schizotypal, para- The infant’s temperament might evoke reactions that accentu-
noid, and borderline—are outlined within the Millon model. ate these early tendencies; in other words, the infant’s innate
These severe variants theoretically represent extensions of the endowment shapes his or her behavior as well as his or her
other mild–moderate personality patterns that have proven parents’ behavior. Additionally, each parent brings his or her
less proficient or ineffective in securing consistent reinforce- respective histories, expectations, and personality styles to
ment or have faltered in the face of sustained and intense this new relationship. A key insight was that a “circularity of
stress. The underlying patterns become exaggerated, more interaction” develops that influences this relationship and
desperate, or more extreme in their perceptions, thoughts, and gradually affects the child’s emerging personality style
actions, and periodically suffer from lapses in reality testing. (Millon, 2011).
In preteens and adolescents, the unstable style represents a As biology–nature and environment–nurture interact, this
mild variant along the borderline personality spectrum or a dynamic interplay will influence whether the infant establishes
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potential precursor to the more severe variant (Millon, 2011). a secure or insecure attachment with each parent (Bowlby,
This personality style, recognizable for its intense endogenous 1988). Millon’s theory emphasizes the importance of a child
moods, pervasive ambivalence, and inconstancy, is character- possessing a “secure base” and the ramifications if he or she
ized by conflicts within all three polarities. Millon (2011) does not. According to Millon’s neuropsychological stages of
summarized these conflicts in this manner: “Each polarity development, which correspond to the theory’s underlying
position is but a temporary one, quickly jettisoned for its polarities, attachment plays a central role with regard to attain-
opposite” (p. 909); hence, the unpredictable behaviors, labile ing the goals identified for each stage. The first stage, sensory-
moods, vacilllating thoughts, volatile relationships, and iden- attachment, is connected to the pleasure (life-enhancement)–
tity confusion seen with this pattern. pain (life preservation) polarity. The sensory component high-
Millon was attuned to developing trends, and he was espe- lights that infants spend the first year of their lives responding
cially concerned about the increasing prevalence of the bor- to the world through sensory processes. Most learn what
derline personality throughout the 1980s and 1990s, especially actions, situations, and experiences—life-enhancing activi-
among young people. He appreciated the importance of early ties—lead to pleasure and to avoid—through life-preserving
identification and developed the Millon Adolescent Clinical activities—those circumstances that lead to pain. The attach-
Inventory’s (MACI) Borderline Tendency scale for this pur- ment component begins with the need to attach to survive
pose (Millon, Millon, & Davis, 1993). Millon (1987) authored through proximity to the primary caretaker, then later shifts
an article in the Journal of Personality Disorders, a journal he into identifying who is available as a reliable source of nour-
founded and initially coedited with Allen Frances, that ishment, stimulus nutriment, and security. The development
addressed this trend from a social learning perspective. His of internal working models (Bowlby, 1969, 1980; Bretherton
cogent argument identified “two broad sociocultural trends” & Munholland, 2008), which assists in achieving the differen-
that contributed to an “epidemic” of borderline personality tiation between self and object, also prepares the infant to
disorder. On one hand, there was the “emergence of social anticipate what might happen in his or her future interactions
customs that exacerbate rather than remediate early, errant with significant others. The second stage, sensorimotor-auton-
parent–child relationships,” which included rapid changes in omy, is related to the active (ecologically modifying)–passive
social values and norms, changes in family structures, the (ecologically accommodating) polarity. In this stage, the child
impact of technology and social media, and the accessibility is learning different “modes of adaptation”—an active stance
of mind-altering drugs. On the other, there was a concurrent involves taking initiative and exploring the world through
decrease in the influence of reparative institutions, the avail- action, whereas a passive stance reflects a watch, wait, and
ability of positive role models, and a sense of genuine social “accept-what-is-given” approach. Millon’s model proposed
connectedness and purpose. Adolescents caught in these pre- that those children with a secure attachment will have more
dicaments would be at increased risk and vulnerability if they self-confidence and welcome more opportunities to develop
were not reared in stable and predictable environments, did competencies in comparison to those with an insecure attach-
not establish secure attachments, did not possess particular tal- ment who might be more timid, hesitant to venture out, and
ents or develop particular skills, did not connect with a posi- limited by fears. Children could develop stylistic preferences
tive role model, and did not demonstrate resiliency. over time because the outcomes are intrinsically rewarding
(pleasure) or because they reduce anxiety and discomfort
(pain avoidance). With increased verbal capacity and entrance
THEORY: NEUROPSYCHOLOGICAL STAGES into complex social, academic, and extracurricular settings,
According to the Millon model, each infant is born with cer- children will further develop representations of others and
tain biologically based dispositions and attributes that set in themselves, including their strengths and weaknesses. Millon
motion different interactions and, in turn, experiences with his postulated that the cumulative experiences of the first 10 years
or her environment. Temperament plays a role in terms of or so set the foundation for the child’s entrance into the third
how the early infant–parent bond will develop and how mutu- stage, the pubertal-gender identity stage, which is associated
ally rewarding the relationship will be. Infants who are calm, with the self (individual propagation)– other (progeny nurtur-
easy to soothe, and engaging will most often elicit positive ance) polarity. Success during the child’s negotiation of his or
 566 TRINGONE AND BOCKIAN

her preadolescent and adolescent years will be contingent on Several other important features separated the MAPI from
how secure his or her sense of self is, the nature and quality of its contemporaries. The test had two cross-validation subject
his or her relationships, and his or her ability to establish a pools—nonclinical and clinical participants—so test users
sense of direction and purpose. Throughout this period, the could make appropriate comparisons according to the setting
preadolescent or adolescent is able to modify his or her self- (school or mental health) in which the test was administered.
and other representations according to new experiences; how- The test used prevalence-based base rate scores rather than
ever, it is believed that many interactions will remain stable standardized scores. Millon emphasized that the constructs the
and predictable. Healthy and adaptive personality styles test measured were not normally distributed. In clinical set-
develop from secure attachments, demonstrate flexibility in tings, discriminations were made between clinical target
behaviors that elicit positive reinforcement and minimize neg- groups, not between a clinical group and a normal group. A
ative reinforcement, attain and sustain a balance of meeting key innovation was that scores were tied to base rates of disor-
one’s needs with someone else’s needs, and promote mutually ders in populations, rather than to arbitrary statistical cutoffs.
satisfying relationships. For example, if the rate of depression was 20% in outpatient
clinical settings, a base rate (BR) score of 75 was set at 20%,
thereby attempting to maximize the accuracy of the instru-
PERSONALITY ASSESSMENT ment. Millon embraced technology in regard to computer
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Millon spoke and wrote about a renaissance in personality scoring and the creation of detailed interpretive reports.
theory and personality assessment that was underway in the The MAPI gained a loyal following (Piotrowski & Lubin,
1970s and 1980s (Millon, 1984). He pointed out shifts in psy- 1990), and interest in its clinical utility led to a sizable number
choanalytic, learning, and interpersonal theories, changes in of research studies. One particular area of interest centered on
patient populations and settings in which psychologists disruptive behavior disorders given the high prevalence of
worked, advances in psychometric techniques, and the central these behavior patterns in adolescents (Kay & Kay, 1986).
role given to the personality disorders in the DSM–III as the MAPI profiles often found that the Forceful personality scale
key signs. He was positioned at the forefront of this movement was elevated at clinically significant levels in those adoles-
due to his involvement in the development of the DSM–III, cents with proclivities toward conduct disorders. Among the
growing interest in his theory, and the clinical utility psychol- central features of this personality pattern are a strong desire
ogists found in the Millon Clinical Multiaxial Inventory for autonomy, acting out and rebellious behaviors, callous and
(MCMI; Millon, 1977). The field was waiting for and welcom- hostile moods, and a mistrust of others due to perceived injus-
ing of new measures because self-report tests were believed to tices and slights. From Millon’s perspective, the personality
be reliable and valid, quick to administer, and they provided patterns scales were constructed to provide the context within
clinically rich material. He altered the adolescent personality which to consider other scale elevations. For conduct-disor-
assessment landscape with the introduction of the Millon dered adolescents, high scores on the Forceful scale were
Adolescent Personality Inventory (MAPI; Millon, Green, & accompanied by co-elevations on the Impulse Control, Socie-
Meagher, 1982). The MAPI is a 150-item, true–false inven- tal Compliance, and Family Rapport scales, which measured
tory, normed on a large sample of nonclinical and clinical sub- clinical correlates of poor impulse control and frustration
jects 13 to 18 years old. Unlike other instruments available at tolerance, noncompliance and illegal activities, and family
the time that had been designed for adults and later modified conflicts. This clinical profile was reported in community
or renormed for adolescents, the MAPI was specifically writ- (Holcomb & Kashani, 1991) and inpatient (Hart, 1993) sam-
ten for adolescents, with the items written at a sixth-grade ples. Furthermore, elevations on the Forceful scale, post-
reading level. It assessed behavior correlates (four scales) and discharge following lengthy psychiatric hospitalizations, were
expressed concerns (eight scales) common to the cohort within associated with poor prognoses (Pantle, Barger, Hamilton,
the context of personality styles (eight scales). Millon fol- Thornton, & Piersma, 1994).
lowed Loevinger’s (1957) three-phase sequence of construc- Another area of research activity focused on depressive dis-
tion and validation, which was innovative methodology at the orders. Millon often wrote about how certain personality types
time. His theory provided the foundation to satisfy the first were susceptible to certain stressors and how they would man-
stage, theoretical-substantive, during which items were written ifest distress in different ways. Piersma, Pantle, Smith, Boes,
to describe the essence of eight basic personality styles out- and Kubiak (1993), reporting on a sample of 94 depressed hos-
lined by the theory. To satisfy the second stage, these items pitalized adolescents, found that the MAPI mean profiles for
and subsequent scales were subjected to several empirical tests this group were elevated on the Inhibited and Sensitive per-
(e.g., item-to-scale correlations, scale intercorrelations, and sonality scales as well as the Self Concept, Personal Esteem,
factor analysis) to measure their internal structural validity. Body Comfort, Peer Security, and Family Rapport expressed
Item overlap, those instances in which a subject’s endorse- concerns scales. In several studies, the same MAPI personality
ment of a single item led to loadings on several scales, was a scales, Inhibited and Sensitive, were found to have statistically
frequent criticism for the Millon inventories and was chal- significant correlations with other self-report measures of
lenged by the question, “Were scale intercorrelations artifi- depression. For example, Pantle, Evert, and Trenerry (1990)
cially inflated because the scales shared common items?” reported a median correlation above .60 between the MAPI’s
Millon believed that certain scales were theoretically expected Inhibited scale and the 10 scales of the Multiscore Depression
to relate to one another and that this was a more accurate Inventory (MDI; Berndt, 1986), and a median correlation just
reflection of the nature of personality styles. The MAPI was below .60 between the MAPI’s Sensitive scale and the same
then correlated with other available measures to assess its 10 scales. Ehrenberg, Cox, and Koopman (1990) had more
external-criterion validity. than 300 high school students complete the MAPI and the
 PREADOLESCENT AND ADOLESCENT PERSONALITY ASSESSMENT 567

Beck Depression Inventory (BDI; Beck, Ward, Mendelson, anorexia nervosa scored at or above this level on the Coop-
Mock, & Erbaugh, 1961). A principal components analysis erative and Respectful scales.
was conducted using the MAPI’s 20 scales and the BDI total Overall, the MAPI was well-received; however, a signifi-
score. Two factors emerged, which were interpreted to repre- cant number of clinicians who administered the test suggested
sent what Millon would call subtypes. The first depressive to Millon that he consider adding specific scales to assess
subtype was associated with high scores on the Inhibited and common clinical syndromes (e.g., anxiety, depression, etc.)
Sensitive personality scales as well as five expressed concerns they would encounter. Additionally, through the 1980s, Millon
scales: Self-Concept, Personal Esteem, Body Comfort, Sexual revised his theory to include two more personalities that had
Acceptance, and Peer Security. These scales are typically been introduced in the DSM–III–R Appendix. As a result, the
associated with an “internalizing” clinical picture. The second MACI (Millon et al., 1993) was conceived and represented a
depressive subtype, in contrast, was associated with high significant change from its predecessor (Millon & Davis,
scores on the Forceful and Sensitive personality scales as well 1993). First, the MACI was exclusively normed with an ado-
as the Family Rapport, Impulse Control, and Societal Compli- lescent clinical population from diverse clinical settings. Sec-
ance scales. These scales are more often associated with acting ond, the new instrument shared fewer than 50 items with its
out or “externalizing” clinical pictures, which might “mask” predecessor. Third, the personality patterns section was
underlying depressive conditions. Such studies illustrated the expanded from 8 to 12, including the Borderline Tendency
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importance of understanding clinical syndromes within the scale. Fourth, five new Clinical Syndrome scales were added
context of a person’s personality. In other words, two adoles- to assess anxiety, depression, disordered eating patterns, sub-
cents might meet criteria for a specific clinical syndrome (e.g., stance use, and suicidality. Fifth, three modifying indexes
depression) that would be addressed clinically; however, the were created to adjust scale profiles according to a subject’s
added information of an adolescent’s underlying personality test-taking approach. Sixth, the interpretive reports were
could lead to a more customized treatment. restructured to include diagnostic impressions and treatment
Johnson, Archer, Sheaffer, and Miller (1992) conducted an considerations. The MACI offered keen insights into an
examination between the MAPI and the Minnesota Multi- adolescent’s personality in the context of maturational
phasic Personality Inventory (MMPI) with an adolescent clini- changes, developmental progressions, family interactions, and
cal sample. The results indicated that the MAPI’s Inhibited social challenges. The explicative “story” of the dynamic
personality scale had significant positive correlations with 10 interplay of these forces, what might unfold if the pattern held
out of 10 of the MMPI’s clinical scales, whereas the MAPI’s its course, and points to consider in helping an adolescent
Sensitive scale had significant positive correlations with 8 of negotiate these circumstances to a more adaptive or healthier
the MMPI’s clinical scales. A combination of elevated scores outcome appealed to clinicians. The MACI was developed
on the MAPI’s Inhibited and Sensitive scales was found in with a large clinical sample from various treatment settings,
40% of an adolescent sample (N D 102) that had been hospi- and its scales demonstrated strong internal and external (crite-
talized following a suicide attempt (Fritsch, Donaldson, Spi- rion and concurrent) validity (Millon et al., 1993). The MACI
rito, & Plummer, 2000). These adolescents were administered generated considerable research interest, and close to 100
the MAPI and the Hopelessness Scale for Children (HSC; studies have been conducted with it. Independent researchers
Kazdin, Rodgas, & Colbus, 1986) and then were divided into have substantiated its sound psychometric foundation and
two groups: low hopelessness and high hopelessness. The lat- diagnostic efficiency, in particular, when looking at mood dis-
ter group was found to have statistically significant higher orders, behavior disorders, and substance use disorders (Pinto
scores on the Inhibited and Sensitive scales and statistically & Grilo, 2004).
significant lower scores on the Confident and Respectful For roughly the past 20 years, the MACI has been one of
scales. The high hopelessness group also had significantly the most popular objective personality inventories due to its
higher mean scores on all of the expressed concerns and brevity (160 true–false items) and scope. Clinicians who
behavioral correlates scales. Overall, high scores on the administer the test have learned that elevations on the Border-
MAPI’s Inhibited and Sensitive scales represented an adoles- line Tendency scale are noteworthy, as it serves as a severity
cent in distress and at risk for severe mood and behavior disor- gauge by identifying adolescents with more serious psycho-
ders. These adolescents typically reported peer and family logical problems. It was constructed later in the MACI’s
relations that were troubling to them and were frequently areas development so it does not have its own prototype items (i.e.,
of conflict rather than protective resources. They struggled to items written specifically for the scale at the beginning of the
develop a cohesive and positive sense of self, which left them development process). Instead, it is a compilation of 21 items
vulnerable to ongoing struggles. from 10 scales that address many of the core features of the
Elevations on the MAPI’s Inhibited and Sensitive scales borderline personality. Adolescents who attain high scores on
were found with other clinical populations as well. For this scale typically experience episodes of marked behavioral
example, Pryor and Wiederman (1998), reporting on a sam- and emotional dysregulation. In these adolescents, there is a
ple of adolescent females diagnosed with anorexia nervosa lack of constancy that permeates all domains and is manifest
(n D 26) or bulimia nervosa (n D 30), found that 46% of in their intense ambivalence, labile moods, unpredictable
the former group and 50% of the latter group scored at or behaviors, capricious thoughts, and identity diffusion.
above the base rate cutoff score of 75 on the Inhibited scale. Creating the Borderline Tendency scale added tremendous
However, clear distinctions between the groups emerged on clinical utility to the instrument. Millon’s perspicacity in rec-
the other scales. Of those diagnosed with bulimia nervosa, ognizing the alarming rate at which adolescents manifested
63% scored at or above the cutoff score on the Sensitive this pattern and his appreciation of its nuances led him to
scale. In contrast, over 60% of those diagnosed with develop a measure that could identify adolescents at risk. He
 568 TRINGONE AND BOCKIAN

believed in personality spectra and that stable and enduring according to their PCL–R scores, into a psychopathic group
personality traits had their origins in a person’s early years. At (highest third) and a nonpsychopathic group (lowest third).
the same time, though, he believed that early identification The MACI profiles of these respective groups showed statisti-
could lead to early intervention, which could change the tra- cally significant higher scores for the psychopathic group on
jectory of these traits and their impact on a person’s life. Stud- the Unruly, Forceful, and Oppositional personality scales,
ies have highlighted the connection between emerging Delinquent Predisposition, Impulsive Propensity, and Sub-
borderline personality traits and histories of childhood abuse stance Abuse Proneness clinical syndrome scales, and the
(Grilo, Sanislow, Fehon, Martino, & McGlashan, 1999) as Social Insensitivity and Identity Diffusion expressed concerns
well as suicide attempts (Velting, Rathus, & Miller, 2000). In scales. Also, statistically significant lower scores for this
a recent study, Yalch, Hopwood, Fehon, and Grilo (2014) group were found on the Submissive personality scale, Anx-
explored whether borderline features, measured with the Bor- ious Feelings clinical syndrome scale, and the Sexual Discom-
derline Tendency scale, were associated with suicide risk. fort expressed concerns scale. The MACI’s Substance Abuse
They collected self-report data from more than 475 psychiatri- Proneness, Unruly, Delinquent Predisposition, Impulsive Pro-
cally hospitalized adolescents on the MACI, Suicide Risk pensity, and Social Insensitivity scales had the highest positive
Scale (SRS; Plutchik, van Praag, Conte, & Picard, 1989), BDI statistically significant correlations with the PCL–R. The
(Beck et al., 1961), and Alcohol Abuse Involvement Scale authors also developed a MACI Psychopathy Content scale.
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(AAIS; Mayer & Filstead, 1979). They conducted a factor The scale, made up of 20 MACI items, showed a strong posi-
analysis of the Borderline Tendency scale and identified three tive correlation (r D .60) with the PCL–R and showed promise
factors related to self-harm, impulsivity, and identity distur- as it was able to discriminate between the psychopathic and
bance. A hierarchical linear regression model was developed nonpsychopathic groups at an 83% accuracy rate.
to test the incremental value of these three factors while con- In a follow-up study, Murrie and Cornell (2002) compared
trolling for the effects of depression and substance use. They three separate screening measures, including the MACI’s Psy-
found that these factors did provide statistically significant chopathy Content scale, with the Psychopathy Checklist:
incremental information about suicide risk after controlling Youth Version (PCL:YV; Forth, Kosson, & Hare, 2003). The
for symptoms of depression and substance (alcohol and drug) Psychopathy Content scale showed the highest correlation (r
use. Although this study illuminates the connections between D .49) with the PCL:YV and the largest Receiving Operator
these clinical issues in a retrospective manner, it will be Characteristic effect size of the three screening measures;
important to also investigate them in a prospective manner. however, none of the measures, alone or in combination, were
Millon’s conceptualization of personality subtypes, which able to reach acceptable overall classification accuracy rates.
he first proposed more than 30 years ago (Millon, 1981), con- In a related study, Salekin, Ziegler, Larrea, Anthony, and
tinues to gain support through sophisticated quantitative anal- Bennett (2003) set out to investigate the MACI’s predictive
yses. In a recent study, Ramos, Canta, de Castro, and Leal validity of recidivism with an adolescent offender sample.
(2014) set out to identify “subgroups” within a sample of ado- More specifically, the authors tested the Murrie–Cornell Psy-
lescents (N D 60) who met DSM criteria for a borderline per- chopathy Content scale, which they divided into three sub-
sonality disorder diagnosis. A latent class analysis identified scales—egocentricity, antisocial behaviors, and substance
two discrete “subgroups,” which the authors labeled abuse—and another content scale that they developed and
“internalizing” and “externalizing.” They concluded, consis- labeled the P-16 scale. (This “psychopathy” scale is made up
tent with Millon’s theory, that the borderline personality cate- of 16 MACI items, of which 8 are shared with the Murrie–
gory represents a heterogeneous group and each feature has Cornell Psychopathy Content scale). The P-16 scale has three
important clinical implications regarding its development and subscales also—egocentricity, callousness, and antisociality.
treatment. Both content scales demonstrated predictive validity of gen-
The introduction of the MACI stimulated another round of eral and violent recidivism and number of offenses 2 years
research activity focused on disruptive behavior disorders and later; however, the highest correlations with all three recidi-
psychopathy. With the MACI’s new scales, a very common vism measures were found with the P-16 total score and two
profile for conduct-disordered adolescents was found to of its subscales, callousness and antisociality.
include elevations on the Unruly, Forceful, and Oppositional The inclusion of the Substance Abuse Proneness scale
personality scales, the Delinquent Predisposition and Impul- underscores the importance of assessing alcohol and drug use
sive Propensity clinical syndrome scales, and the Social Insen- in adolescents. During the MACI’s development phase, this
sitivity expressed concerns scale (McCann, 1999). The co- scale was externally validated with the Problem Oriented
elevations of these three personality scales form an “anger- Screening Instrument for Teenagers (POSIT; National Insti-
hostility triad” (Tringone, 2008), which is consistent with ado- tute on Drug Abuse, 1991). The MACI’s Substance Abuse
lescents who display antagonistic, hostile, and impulsive Proneness scale was correlated at r D .64 with the POSIT
behaviors. These adolescents possess a nonempathic and self- test’s Substance Use or Abuse subscale. Grilo, Fehon, Walker,
centered attitude, exhibit a disregard for the welfare of others, and Martino (1996) compared MACI profiles of psychiatri-
and interact in a socially intimidating manner. They are will- cally hospitalized adolescents with substance use disorders
ing to challenge authority and take risks without heeding and those without. Overall, the group with substance use dis-
warnings of negative consequences. Murrie and Cornell orders scored significantly higher on the MACI’s Substance
(2000), in a study of 90 psychiatrically hospitalized adoles- Abuse Proneness scale as well as the Unruly and Forceful per-
cents, set out to compare the MACI’s ability to assess and sonality scales, Delinquent Predisposition and Impulsive Pro-
identify psychopathy as measured by the Psychopathy Check- pensity clinical syndrome scales, and Social Insensitivity
list–Revised (PCL–R; Hare, 1991). Subjects were divided, expressed concerns scale. Additionally, this group scored
 PREADOLESCENT AND ADOLESCENT PERSONALITY ASSESSMENT 569

significantly lower on the Submissive, Inhibited, and Introver- The M–PACI is the only instrument for 9 to 12-year-olds
sive personality scales; the Anxious Feelings clinical syn- that identifies common clinical problems within the context of
drome scale; and the Sexual Discomfort expressed concerns a preadolescent child’s emerging personality style (Kamp &
scale. These results showed an association between substance Tringone, 2008). The instrument does not assess for personal-
abuse problems and externalizing patterns; however, this ity disorders and, consistent with Millon’s notion of personal-
likely represents one subtype because adolescents with inter- ity spectra, the M–PACI’s interpretive reports initially focus
nalizing patterns also turn to alcohol and drugs. on the adaptive qualities of each personality pattern before
The MACI has been the subject of several studies investi- addressing features that might be clinically significant or dis-
gating its underlying factor structure. Adkisson, Burdsal, ruptive to the child’s intrapersonal or interpersonal develop-
Dorr, and Morgan (2012) compared different models in 300 ment and functioning.
psychiatrically hospitalized adolescents and determined that a The M–PACI consists of 14 scales: 7 emerging personal-
three-factor solution best fit the data. The three factors they ity patterns and scales and 7 current clinical signs scales.
extracted—demoralization, acting out, and detached— Among the emerging personality pattern scales are the
accounted for 82% of the total variance. The first factor had “core four”—the interpersonally imbalanced personalities.
positive loadings (all above .70) on the Borderline Tendency, They are labeled the submissive, outgoing, confident, and
Self-Demeaning, Doleful, and Oppositional personality scales; unruly personalities, and they correspond to the more path-
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and the Eating Dysfunctions, Depressive Affect, and Suicidal ological dependent, histrionic, narcissistic, and antisocial
Tendency clinical syndrome scales; and negative loadings personalities. Two other common emerging personality
(below ¡.40) on the Egotistic and Conforming personality patterns, inhibited and conforming, correspond to the avoi-
scales. The second factor had positive loadings (all above .70) dant and obsessive–compulsive personalities. The last
on the Unruly and Forceful personality scales and the Delin- scale, the unstable emerging personality pattern, is related
quent Predisposition clinical syndrome scale, and negative to the borderline personality. Similar to the MACI’s Bor-
loadings (below ¡.50) on the Submissive and Conforming derline Tendency scale, elevations on the M–PACI’s
personality scales and the Anxious Feelings clinical syndrome Unstable scale are associated with more significant dis-
scale. Finally, the third factor had positive loadings on the tress, which is most evident in mood lability. The seven
Introversive and Inhibited personality scales and negative current clinical signs scales include Anxiety/Fears, Atten-
loadings on the Dramatizing and Egotistic personality scales. tion Deficits, Obsessions/Compulsions, Conduct Problems,
Other studies have employed different statistical procedures Disruptive Behaviors, Depressive Moods, and Reality Dis-
and have found similar factors although not in the same order tortions. Additionally, the M–PACI has a validity indica-
regarding explained variance. The most probable explanation tor, labeled response negativity, which is reported as a
is that researchers have conducted their respective studies percentile score. Very high scores reflect response patterns
with different adolescent populations, which might have dif- that are both negative and nonspecific, implying a broad
ferent prevalence rates for the various conditions they study range of problem areas. Very low scores, in contrast,
and the settings they are in. These subjects have included reflect more positive impressions. It is up to the clinician
male (Amato, Cornell, & Fan, 2008; Stefurak, Calhoun, & to determine what condition or motivation might have led
Glaser, 2004) and female youth offenders (Stefurak & Cal- the child to potentially exaggerate his or her profile in a
houn, 2007) as well as participants in residential treatment negative or positive direction (Tringone, Millon, & Kamp,
facilities (Romm, Bockian, & Harvey, 1999) and psychiatric 2007).
hospitals (Adkisson et al., 2012). Finally, other researchers Early research with the M–PACI suggests that some per-
have assessed adolescents from diverse cultural backgrounds sonality styles appear to be associated with sufficient cop-
(Blumentritt, Angle, & Brown, 2004; McMahon et al., 2013) ing resources or a sense of resiliency in that they are able
and reported how cultural factors might impact MACI results. to handle stress or respond to it in an effective manner,
With the turn of the century, Millon turned his attention to a whereas other personality styles wither under the weight of
“new” phase of the life span known as preadolescence. Many or potentially perpetuate their troubles (Millon et al., 2005;
children seemed to be accelerating through childhood, physi- Tringone, 2008). For example, the M–PACI’s Confident,
cally, socially, and emotionally. Yet many found themselves Outgoing, and Conforming scales have all demonstrated
struggling to meet the challenges before them. At the time, positive correlations with one another, and the first two
there were very few self-report inventories for children below scales have had negative correlations with all the other M–
the teenage years. Also, many of these inventories measured PACI scales. Additionally, these same three scales demon-
single constructs or, if considered a personality test, they did strated negative correlations with the Behavior Assessment
not have separate personality scales. Millon saw a niche to be System for Children–Self-Report of Personality–Child 8–
filled with the Millon Pre-Adolescent Clinical Inventory 11 version (BASC–SRP–C; Reynolds & Kamphaus, 1998)
(M–PACI; Millon, Tringone, Millon, & Grossman, 2005). Clinical Scales and positive correlations with the BASC–
Construction of the M–PACI presented several challenges. SRP–C’s Adaptive Scales. On the other hand, strong posi-
What personality styles have formed to a sufficient degree by tive correlations were found between the M–PACI’s Sub-
that age? How does one measure those styles in a reliable and missive and Inhibited scales with the Anxiety/Fears,
valid manner in this age group? How does one construct items Obsessions/Compulsions, and Depressive Moods scales as
that children can understand what they are being asked to well as the Children’s Depression Index (CDI; Kovacs,
report about themselves? The task was an ambitious undertak- 2001) and the Revised Children’s Manifest Anxiety Scale
ing and, through Millon’s leadership and expertise, another (Total Score [RCMAS]; Reynolds & Richmond, 2000),
member was added to the Millon inventories family. which appear to suggest internalizing tendencies or
 570 TRINGONE AND BOCKIAN

vulnerabilities. The M–PACI’s Unruly scale, in contrast, personality assessment field to carry “onward and upward,”
had strong positive correlations with the Disruptive Behav- in the name of science, yes, but the ultimate task is to
iors and Conduct Problems scales, which is suggestive of make a difference in a child’s life.
externalizing behavior tendencies. The most vulnerable
children, however, appear to be those who obtain eleva-
tions on the M–PACI’s Unstable scale. This scale demon- REFERENCES
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