Journal of Personality Assessment

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

563
 564
other prominent theories at the time. He incorporated and
expanded on illuminative ideas from his primary influen-
ces—Gardner Murphy, Ernst Kris, and Kurt Goldstein—
who stressed that patterns become gradually ingrained
through repeated experiences, that the person and environ-
ment mold one another, and that a holistic approach to the
person is the most clinically sound one. A multitude of fac-
tors influence personality development. Each person pos-
sesses a distinctive set of biological predispositions, has his
or her own unique developmental experiences, faces a wide
range of sociocultural influences, and must deal with what-
ever random events might occur in his or her life. Although
we might have little to no control over some of these fac-
tors, it is generally accepted that parent–child interactions
affect a child’s developing personality. Millon believed
that personality and, in turn, psychopathology, progresses
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through a “developmental process in which intra-organismic
and environmental forces display not only a reciprocity and
circularity of influence but an orderly and sequential conti-
nuity throughout the life of the individual” (Millon, 1969, p.
210). He formulated, in a systematic manner, what those
experiences might entail for each personality pattern recog-
nized in the current nomenclature and others that can be
derived according to his theory.
THEORY: PERSONALITY POLARITIES
Millon’s personality theory (1969, 1981, 2011; Millon &
Davis, 1996) is founded on three polarities: pleasure–pain,
active–passive, and self–other. These polarities are configured
to conceptualize personality patterns that exist on a spectrum
from normal to disorder. The model was originally formulated
as a biosocial learning theory with an emphasis on reinforce-
ment (Millon, 1969, 1981). Personality patterns were viewed
as learned strategies to secure positive reinforcement and min-
imize punishment. The pleasure–pain polarity represented
the nature of the response elicited from others, which could
be positive (pleasure) or negative (pain). The active–passive
polarity represented the behavior employed to maximize
rewards and minimize pain, and the self–other polarity repre-
sented the source to which an individual turned for reinforce-
ment. Millon later reconceptualized his theory as an
evolutionary model (Millon, 1990, 2011; Millon & Davis,
1996). At this level, the polarities represent life functions or
divisions. For example, the pleasure–pain polarity represents
existence in terms of life enhancement (pleasure) versus life
preservation (pain). The active–passive polarity represents life
forms in which the active polarity includes the animal king-
dom, and the passive polarity includes the plant kingdom. Of
course, there are exceptions to each group, but the majority of
members of the animal kingdom are mobile and take action to
secure reinforcement or assure their existence, whereas the
majority of members of the plant kingdom are stationary,
must accommodate to what the environment offers them, and
rely on the environment to provide reinforcement or suste-
nance to exist. The self–other polarity highlights the two pri-
mary reproductive strategies—self-focused (r-strategy—male
orientation) in terms of potentially having multiple partners
and a multitude of progeny, while assuming limited childrear-
ing responsibilities, and other-focused (K-strategy—female
TRINGONE AND BOCKIAN
orientation) in terms of investing considerable time and energy
nurturing few offspring.
In the Millon system, these polarities are combined to
derive and explicate the essence of each personality style as a
personality prototype. Additionally, they explain the central
underlying and reciprocally reinforcing dynamics of each pat-
tern. Four “core” personality styles are theoretically identified
as “interpersonally imbalanced.” For these personality styles,
the central polarity is the self–other polarity in which there is
a strong emphasis on one source of reinforcement at the
expense of the other. Dependent types look to others for a
sense of security and pain avoidance, whereas independent
types rely on themselves for similar needs. These types are
further divided into active and passive variants. The active
dependent types correspond to the histrionic personality with
its persistent seeking of stimulation and excitement as well as
its solicitous efforts to secure attention and affection from
multiple attachment figures, whereas passive dependent types
correspond to the dependent personality, which is well recog-
nized for its strong need to attach to a significant other for a
sense of safety and security as well as its willingness to subor-
dinate its own desires to please someone else. The passive
independent types in this system correspond to the narcissistic
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
level of self-worth. As a result, they can feel content and
secure just being themselves. The active independent types, in
contrast, have typically had difficult upbringings and might
have experienced the world as an uncaring, ungiving, and hos-
tile or even dangerous place. Others cannot be relied on and,
with a precarious sense of security, the antisocial personality
learns to take care of his or her own needs by whatever means
necessary, even if it involves violating rules and the rights of
others.
Four other personality styles are labeled intrapsychically
conflicted. The ambivalent types experience an intense conflict
within the self–other polarity over whether to look to self or to
others as the source of reinforcement. The compulsive person-
ality (passive ambivalent variant) attempts to resolve the con-
flict through compliance and accommodation to others by
acting in responsible and conscientious ways as well as adher-
ing to strict sets of rules that govern their behavior. The nega-
tivistic personality (active ambivalent variant), on the other
hand, endures an invidious struggle that impacts virtually all
domains of life. Two discordant types, the sadistic (active var-
iant) and masochistic (passive variant) personalities, approach
life and relationships according to a reversal within the plea-
sure–pain polarity. The former personality derives pleasure
from inflicting pain (fear, stress) and exerting power (control,
dominance) over others in an assertive manner, whereas the
latter personality’s interactions and intimate relationships
leave them feeling aggrieved.
Detached types turn neither to self or others for positive
reinforcement. The avoidant personality is conceptualized as
the active detached pattern. These personalities withdraw in a
self-protective manner to avoid pain, typically suffer from low
self-esteem, and have limited coping resources. An imbalance
within the pleasure–pain polarity also exists given their
propensity to anticipate pain and limited focus on pleasure.
 PREADOLESCENT AND ADOLESCENT PERSONALITY ASSESSMENT
The schizoid personality is conceptualized as the passive
detached type. These personalities seem to have a limited
capacity to experience either psychic pleasure or pain and pos-
sess an intrinsically weak motivation to seek out rewards
through social contact with others.
Three more severe personality variants—schizotypal, para-
noid, and borderline—are outlined within the Millon model.
These severe variants theoretically represent extensions of the
other mild–moderate personality patterns that have proven
less proficient or ineffective in securing consistent reinforce-
ment or have faltered in the face of sustained and intense
stress. The underlying patterns become exaggerated, more
desperate, or more extreme in their perceptions, thoughts, and
actions, and periodically suffer from lapses in reality testing.
In preteens and adolescents, the unstable style represents a
mild variant along the borderline personality spectrum or a
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potential precursor to the more severe variant (Millon, 2011).
This personality style, recognizable for its intense endogenous
moods, pervasive ambivalence, and inconstancy, is character-
ized by conflicts within all three polarities. Millon (2011)
summarized these conflicts in this manner: “Each polarity
position is but a temporary one, quickly jettisoned for its
opposite” (p. 909); hence, the unpredictable behaviors, labile
moods, vacilllating thoughts, volatile relationships, and iden-
tity confusion seen with this pattern.
Millon was attuned to developing trends, and he was espe-
cially concerned about the increasing prevalence of the bor-
derline personality throughout the 1980s and 1990s, especially
among young people. He appreciated the importance of early
identification and developed the Millon Adolescent Clinical
Inventory’s (MACI) Borderline Tendency scale for this pur-
pose (Millon, Millon, & Davis, 1993). Millon (1987) authored
an article in the Journal of Personality Disorders, a journal he
founded and initially coedited with Allen Frances, that
addressed this trend from a social learning perspective. His
cogent argument identified “two broad sociocultural trends”
that contributed to an “epidemic” of borderline personality
disorder. On one hand, there was the “emergence of social
customs that exacerbate rather than remediate early, errant
parent–child relationships,” which included rapid changes in
social values and norms, changes in family structures, the
impact of technology and social media, and the accessibility
of mind-altering drugs. On the other, there was a concurrent
decrease in the influence of reparative institutions, the avail-
ability of positive role models, and a sense of genuine social
connectedness and purpose. Adolescents caught in these pre-
dicaments would be at increased risk and vulnerability if they
were not reared in stable and predictable environments, did
not establish secure attachments, did not possess particular tal-
ents or develop particular skills, did not connect with a posi-
tive role model, and did not demonstrate resiliency.
THEORY: NEUROPSYCHOLOGICAL STAGES
According to the Millon model, each infant is born with cer-
tain biologically based dispositions and attributes that set in
motion different interactions and, in turn, experiences with his
or her environment. Temperament plays a role in terms of
how the early infant–parent bond will develop and how mutu-
ally rewarding the relationship will be. Infants who are calm,
easy to soothe, and engaging will most often elicit positive
565
responses from their parents, especially those parents who are
perceptive and well-attuned to their child’s needs. On the
other hand, infants who have a restive disposition, who might
have trouble regulating their eating and sleep patterns, or who
seem difficult to comfort could elicit very different responses.
The infant’s temperament might evoke reactions that accentu-
ate these early tendencies; in other words, the infant’s innate
endowment shapes his or her behavior as well as his or her
parents’ behavior. Additionally, each parent brings his or her
respective histories, expectations, and personality styles to
this new relationship. A key insight was that a “circularity of
interaction” develops that influences this relationship and
gradually affects the child’s emerging personality style
(Millon, 2011).
As biology–nature and environment–nurture interact, this
dynamic interplay will influence whether the infant establishes
a secure or insecure attachment with each parent (Bowlby,
1988). Millon’s theory emphasizes the importance of a child
possessing a “secure base” and the ramifications if he or she
does not. According to Millon’s neuropsychological stages of
development, which correspond to the theory’s underlying
polarities, attachment plays a central role with regard to attain-
ing the goals identified for each stage. The first stage, sensory-
attachment, is connected to the pleasure (life-enhancement)–
pain (life preservation) polarity. The sensory component high-
lights that infants spend the first year of their lives responding
to the world through sensory processes. Most learn what
actions, situations, and experiences—life-enhancing activi-
ties—lead to pleasure and to avoid—through life-preserving
activities—those circumstances that lead to pain. The attach-
ment component begins with the need to attach to survive
through proximity to the primary caretaker, then later shifts
into identifying who is available as a reliable source of nour-
ishment, stimulus nutriment, and security. The development
of internal working models (Bowlby, 1969, 1980; Bretherton
& Munholland, 2008), which assists in achieving the differen-
tiation between self and object, also prepares the infant to
anticipate what might happen in his or her future interactions
with significant others. The second stage, sensorimotor-auton-
omy, is related to the active (ecologically modifying)–passive
(ecologically accommodating) polarity. In this stage, the child
is learning different “modes of adaptation”—an active stance
involves taking initiative and exploring the world through
action, whereas a passive stance reflects a watch, wait, and
“accept-what-is-given” approach. Millon’s model proposed
that those children with a secure attachment will have more
self-confidence and welcome more opportunities to develop
competencies in comparison to those with an insecure attach-
ment who might be more timid, hesitant to venture out, and
limited by fears. Children could develop stylistic preferences
over time because the outcomes are intrinsically rewarding
(pleasure) or because they reduce anxiety and discomfort
(pain avoidance). With increased verbal capacity and entrance
into complex social, academic, and extracurricular settings,
children will further develop representations of others and
themselves, including their strengths and weaknesses. Millon
postulated that the cumulative experiences of the first 10 years
or so set the foundation for the child’s entrance into the third
stage, the pubertal-gender identity stage, which is associated
with the self (individual propagation)– other (progeny nurtur-
ance) polarity. Success during the child’s negotiation of his or
 566
her preadolescent and adolescent years will be contingent on
how secure his or her sense of self is, the nature and quality of
his or her relationships, and his or her ability to establish a
sense of direction and purpose. Throughout this period, the
preadolescent or adolescent is able to modify his or her self-
and other representations according to new experiences; how-
ever, it is believed that many interactions will remain stable
and predictable. Healthy and adaptive personality styles
develop from secure attachments, demonstrate flexibility in
behaviors that elicit positive reinforcement and minimize neg-
ative reinforcement, attain and sustain a balance of meeting
one’s needs with someone else’s needs, and promote mutually
satisfying relationships.
PERSONALITY ASSESSMENT
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Millon spoke and wrote about a renaissance in personality
theory and personality assessment that was underway in the
1970s and 1980s (Millon, 1984). He pointed out shifts in psy-
choanalytic, learning, and interpersonal theories, changes in
patient populations and settings in which psychologists
worked, advances in psychometric techniques, and the central
role given to the personality disorders in the DSM–III as the
key signs. He was positioned at the forefront of this movement
due to his involvement in the development of the DSM–III,
growing interest in his theory, and the clinical utility psychol-
ogists found in the Millon Clinical Multiaxial Inventory
(MCMI; Millon, 1977). The field was waiting for and welcom-
ing of new measures because self-report tests were believed to
be reliable and valid, quick to administer, and they provided
clinically rich material. He altered the adolescent personality
assessment landscape with the introduction of the Millon
Adolescent Personality Inventory (MAPI; Millon, Green, &
Meagher, 1982). The MAPI is a 150-item, true–false inven-
tory, normed on a large sample of nonclinical and clinical sub-
jects 13 to 18 years old. Unlike other instruments available at
the time that had been designed for adults and later modified
or renormed for adolescents, the MAPI was specifically writ-
ten for adolescents, with the items written at a sixth-grade
reading level. It assessed behavior correlates (four scales) and
expressed concerns (eight scales) common to the cohort within
the context of personality styles (eight scales). Millon fol-
lowed Loevinger’s (1957) three-phase sequence of construc-
tion and validation, which was innovative methodology at the
time. His theory provided the foundation to satisfy the first
stage, theoretical-substantive, during which items were written
to describe the essence of eight basic personality styles out-
lined by the theory. To satisfy the second stage, these items
and subsequent scales were subjected to several empirical tests
(e.g., item-to-scale correlations, scale intercorrelations, and
factor analysis) to measure their internal structural validity.
Item overlap, those instances in which a subject’s endorse-
ment of a single item led to loadings on several scales, was a
frequent criticism for the Millon inventories and was chal-
lenged by the question, “Were scale intercorrelations artifi-
cially inflated because the scales shared common items?”
Millon believed that certain scales were theoretically expected
to relate to one another and that this was a more accurate
reflection of the nature of personality styles. The MAPI was
then correlated with other available measures to assess its
external-criterion validity.
TRINGONE AND BOCKIAN
Several other important features separated the MAPI from
its contemporaries. The test had two cross-validation subject
pools—nonclinical and clinical participants—so test users
could make appropriate comparisons according to the setting
(school or mental health) in which the test was administered.
The test used prevalence-based base rate scores rather than
standardized scores. Millon emphasized that the constructs the
test measured were not normally distributed. In clinical set-
tings, discriminations were made between clinical target
groups, not between a clinical group and a normal group. A
key innovation was that scores were tied to base rates of disor-
ders in populations, rather than to arbitrary statistical cutoffs.
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-
ment. Millon embraced technology in regard to computer
scoring and the creation of detailed interpretive reports.
The MAPI gained a loyal following (Piotrowski & Lubin,
1990), and interest in its clinical utility led to a sizable number
of research studies. One particular area of interest centered on
disruptive behavior disorders given the high prevalence of
these behavior patterns in adolescents (Kay & Kay, 1986).
MAPI profiles often found that the Forceful personality scale
was elevated at clinically significant levels in those adoles-
cents with proclivities toward conduct disorders. Among the
central features of this personality pattern are a strong desire
for autonomy, acting out and rebellious behaviors, callous and
hostile moods, and a mistrust of others due to perceived injus-
tices and slights. From Millon’s perspective, the personality
patterns scales were constructed to provide the context within
which to consider other scale elevations. For conduct-disor-
dered adolescents, high scores on the Forceful scale were
accompanied by co-elevations on the Impulse Control, Socie-
tal Compliance, and Family Rapport scales, which measured
clinical correlates of poor impulse control and frustration
tolerance, noncompliance and illegal activities, and family
conflicts. This clinical profile was reported in community
(Holcomb & Kashani, 1991) and inpatient (Hart, 1993) sam-
ples. Furthermore, elevations on the Forceful scale, post-
discharge following lengthy psychiatric hospitalizations, were
associated with poor prognoses (Pantle, Barger, Hamilton,
Thornton, & Piersma, 1994).
Another area of research activity focused on depressive dis-
orders. Millon often wrote about how certain personality types
were susceptible to certain stressors and how they would man-
ifest distress in different ways. Piersma, Pantle, Smith, Boes,
and Kubiak (1993), reporting on a sample of 94 depressed hos-
pitalized adolescents, found that the MAPI mean profiles for
this group were elevated on the Inhibited and Sensitive per-
sonality scales as well as the Self Concept, Personal Esteem,
Body Comfort, Peer Security, and Family Rapport expressed
concerns scales. In several studies, the same MAPI personality
scales, Inhibited and Sensitive, were found to have statistically
significant correlations with other self-report measures of
depression. For example, Pantle, Evert, and Trenerry (1990)
reported a median correlation above .60 between the MAPI’s
Inhibited scale and the 10 scales of the Multiscore Depression
Inventory (MDI; Berndt, 1986), and a median correlation just
below .60 between the MAPI’s Sensitive scale and the same
10 scales. Ehrenberg, Cox, and Koopman (1990) had more
than 300 high school students complete the MAPI and the
 PREADOLESCENT AND ADOLESCENT PERSONALITY ASSESSMENT
Beck Depression Inventory (BDI; Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961). A principal components analysis
was conducted using the MAPI’s 20 scales and the BDI total
score. Two factors emerged, which were interpreted to repre-
sent what Millon would call subtypes. The first depressive
subtype was associated with high scores on the Inhibited and
Sensitive personality scales as well as five expressed concerns
scales: Self-Concept, Personal Esteem, Body Comfort, Sexual
Acceptance, and Peer Security. These scales are typically
associated with an “internalizing” clinical picture. The second
depressive subtype, in contrast, was associated with high
scores on the Forceful and Sensitive personality scales as well
as the Family Rapport, Impulse Control, and Societal Compli-
ance scales. These scales are more often associated with acting
out or “externalizing” clinical pictures, which might “mask”
underlying depressive conditions. Such studies illustrated the
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importance of understanding clinical syndromes within the
context of a person’s personality. In other words, two adoles-
cents might meet criteria for a specific clinical syndrome (e.g.,
depression) that would be addressed clinically; however, the
added information of an adolescent’s underlying personality
could lead to a more customized treatment.
Johnson, Archer, Sheaffer, and Miller (1992) conducted an
examination between the MAPI and the Minnesota Multi-
phasic Personality Inventory (MMPI) with an adolescent clini-
cal sample. The results indicated that the MAPI’s Inhibited
personality scale had significant positive correlations with 10
out of 10 of the MMPI’s clinical scales, whereas the MAPI’s
Sensitive scale had significant positive correlations with 8 of
the MMPI’s clinical scales. A combination of elevated scores
on the MAPI’s Inhibited and Sensitive scales was found in
40% of an adolescent sample (N D 102) that had been hospi-
talized following a suicide attempt (Fritsch, Donaldson, Spi-
rito, & Plummer, 2000). These adolescents were administered
the MAPI and the Hopelessness Scale for Children (HSC;
Kazdin, Rodgas, & Colbus, 1986) and then were divided into
two groups: low hopelessness and high hopelessness. The lat-
ter group was found to have statistically significant higher
scores on the Inhibited and Sensitive scales and statistically
significant lower scores on the Confident and Respectful
scales. The high hopelessness group also had significantly
higher mean scores on all of the expressed concerns and
behavioral correlates scales. Overall, high scores on the
MAPI’s Inhibited and Sensitive scales represented an adoles-
cent in distress and at risk for severe mood and behavior disor-
ders. These adolescents typically reported peer and family
relations that were troubling to them and were frequently areas
of conflict rather than protective resources. They struggled to
develop a cohesive and positive sense of self, which left them
vulnerable to ongoing struggles.
Elevations on the MAPI’s Inhibited and Sensitive scales
were found with other clinical populations as well. For
example, Pryor and Wiederman (1998), reporting on a sam-
ple of adolescent females diagnosed with anorexia nervosa
(n D 26) or bulimia nervosa (n D 30), found that 46% of
the former group and 50% of the latter group scored at or
above the base rate cutoff score of 75 on the Inhibited scale.
However, clear distinctions between the groups emerged on
the other scales. Of those diagnosed with bulimia nervosa,
63% scored at or above the cutoff score on the Sensitive
scale. In contrast, over 60% of those diagnosed with
567
anorexia nervosa scored at or above this level on the Coop-
erative and Respectful scales.
Overall, the MAPI was well-received; however, a signifi-
cant number of clinicians who administered the test suggested
to Millon that he consider adding specific scales to assess
common clinical syndromes (e.g., anxiety, depression, etc.)
they would encounter. Additionally, through the 1980s, Millon
revised his theory to include two more personalities that had
been introduced in the DSM–III–R Appendix. As a result, the
MACI (Millon et al., 1993) was conceived and represented a
significant change from its predecessor (Millon & Davis,
1993). First, the MACI was exclusively normed with an ado-
lescent clinical population from diverse clinical settings. Sec-
ond, the new instrument shared fewer than 50 items with its
predecessor. Third, the personality patterns section was
expanded from 8 to 12, including the Borderline Tendency
scale. Fourth, five new Clinical Syndrome scales were added
to assess anxiety, depression, disordered eating patterns, sub-
stance use, and suicidality. Fifth, three modifying indexes
were created to adjust scale profiles according to a subject’s
test-taking approach. Sixth, the interpretive reports were
restructured to include diagnostic impressions and treatment
considerations. The MACI offered keen insights into an
adolescent’s personality in the context of maturational
changes, developmental progressions, family interactions, and
social challenges. The explicative “story” of the dynamic
interplay of these forces, what might unfold if the pattern held
its course, and points to consider in helping an adolescent
negotiate these circumstances to a more adaptive or healthier
outcome appealed to clinicians. The MACI was developed
with a large clinical sample from various treatment settings,
and its scales demonstrated strong internal and external (crite-
rion and concurrent) validity (Millon et al., 1993). The MACI
generated considerable research interest, and close to 100
studies have been conducted with it. Independent researchers
have substantiated its sound psychometric foundation and
diagnostic efficiency, in particular, when looking at mood dis-
orders, behavior disorders, and substance use disorders (Pinto
& Grilo, 2004).
For roughly the past 20 years, the MACI has been one of
the most popular objective personality inventories due to its
brevity (160 true–false items) and scope. Clinicians who
administer the test have learned that elevations on the Border-
line Tendency scale are noteworthy, as it serves as a severity
gauge by identifying adolescents with more serious psycho-
logical problems. It was constructed later in the MACI’s
development so it does not have its own prototype items (i.e.,
items written specifically for the scale at the beginning of the
development process). Instead, it is a compilation of 21 items
from 10 scales that address many of the core features of the
borderline personality. Adolescents who attain high scores on
this scale typically experience episodes of marked behavioral
and emotional dysregulation. In these adolescents, there is a
lack of constancy that permeates all domains and is manifest
in their intense ambivalence, labile moods, unpredictable
behaviors, capricious thoughts, and identity diffusion.
Creating the Borderline Tendency scale added tremendous
clinical utility to the instrument. Millon’s perspicacity in rec-
ognizing the alarming rate at which adolescents manifested
this pattern and his appreciation of its nuances led him to
develop a measure that could identify adolescents at risk. He
 568
believed in personality spectra and that stable and enduring
personality traits had their origins in a person’s early years. At
the same time, though, he believed that early identification
could lead to early intervention, which could change the tra-
jectory of these traits and their impact on a person’s life. Stud-
ies have highlighted the connection between emerging
borderline personality traits and histories of childhood abuse
(Grilo, Sanislow, Fehon, Martino, & McGlashan, 1999) as
well as suicide attempts (Velting, Rathus, & Miller, 2000). In
a recent study, Yalch, Hopwood, Fehon, and Grilo (2014)
explored whether borderline features, measured with the Bor-
derline Tendency scale, were associated with suicide risk.
They collected self-report data from more than 475 psychiatri-
cally hospitalized adolescents on the MACI, Suicide Risk
Scale (SRS; Plutchik, van Praag, Conte, & Picard, 1989), BDI
(Beck et al., 1961), and Alcohol Abuse Involvement Scale
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(AAIS; Mayer & Filstead, 1979). They conducted a factor
analysis of the Borderline Tendency scale and identified three
factors related to self-harm, impulsivity, and identity distur-
bance. A hierarchical linear regression model was developed
to test the incremental value of these three factors while con-
trolling for the effects of depression and substance use. They
found that these factors did provide statistically significant
incremental information about suicide risk after controlling
for symptoms of depression and substance (alcohol and drug)
use. Although this study illuminates the connections between
these clinical issues in a retrospective manner, it will be
important to also investigate them in a prospective manner.
Millon’s conceptualization of personality subtypes, which
he first proposed more than 30 years ago (Millon, 1981), con-
tinues to gain support through sophisticated quantitative anal-
yses. In a recent study, Ramos, Canta, de Castro, and Leal
(2014) set out to identify “subgroups” within a sample of ado-
lescents (N D 60) who met DSM criteria for a borderline per-
sonality disorder diagnosis. A latent class analysis identified
two discrete “subgroups,” which the authors labeled
“internalizing” and “externalizing.” They concluded, consis-
tent with Millon’s theory, that the borderline personality cate-
gory represents a heterogeneous group and each feature has
important clinical implications regarding its development and
treatment.
The introduction of the MACI stimulated another round of
research activity focused on disruptive behavior disorders and
psychopathy. With the MACI’s new scales, a very common
profile for conduct-disordered adolescents was found to
include elevations on the Unruly, Forceful, and Oppositional
personality scales, the Delinquent Predisposition and Impul-
sive Propensity clinical syndrome scales, and the Social Insen-
sitivity expressed concerns scale (McCann, 1999). The co-
elevations of these three personality scales form an “anger-
hostility triad” (Tringone, 2008), which is consistent with ado-
lescents who display antagonistic, hostile, and impulsive
behaviors. These adolescents possess a nonempathic and self-
centered attitude, exhibit a disregard for the welfare of others,
and interact in a socially intimidating manner. They are will-
ing to challenge authority and take risks without heeding
warnings of negative consequences. Murrie and Cornell
(2000), in a study of 90 psychiatrically hospitalized adoles-
cents, set out to compare the MACI’s ability to assess and
identify psychopathy as measured by the Psychopathy Check-
list–Revised (PCL–R; Hare, 1991). Subjects were divided,
TRINGONE AND BOCKIAN
according to their PCL–R scores, into a psychopathic group
(highest third) and a nonpsychopathic group (lowest third).
The MACI profiles of these respective groups showed statisti-
cally significant higher scores for the psychopathic group on
the Unruly, Forceful, and Oppositional personality scales,
Delinquent Predisposition, Impulsive Propensity, and Sub-
stance Abuse Proneness clinical syndrome scales, and the
Social Insensitivity and Identity Diffusion expressed concerns
scales. Also, statistically significant lower scores for this
group were found on the Submissive personality scale, Anx-
ious Feelings clinical syndrome scale, and the Sexual Discom-
fort expressed concerns scale. The MACI’s Substance Abuse
Proneness, Unruly, Delinquent Predisposition, Impulsive Pro-
pensity, and Social Insensitivity scales had the highest positive
statistically significant correlations with the PCL–R. The
authors also developed a MACI Psychopathy Content scale.
The scale, made up of 20 MACI items, showed a strong posi-
tive correlation (r D .60) with the PCL–R and showed promise
as it was able to discriminate between the psychopathic and
nonpsychopathic groups at an 83% accuracy rate.
In a follow-up study, Murrie and Cornell (2002) compared
three separate screening measures, including the MACI’s Psy-
chopathy Content scale, with the Psychopathy Checklist:
Youth Version (PCL:YV; Forth, Kosson, & Hare, 2003). The
Psychopathy Content scale showed the highest correlation (r
D .49) with the PCL:YV and the largest Receiving Operator
Characteristic effect size of the three screening measures;
however, none of the measures, alone or in combination, were
able to reach acceptable overall classification accuracy rates.
In a related study, Salekin, Ziegler, Larrea, Anthony, and
Bennett (2003) set out to investigate the MACI’s predictive
validity of recidivism with an adolescent offender sample.
More specifically, the authors tested the Murrie–Cornell Psy-
chopathy Content scale, which they divided into three sub-
scales—egocentricity, antisocial behaviors, and substance
abuse—and another content scale that they developed and
labeled the P-16 scale. (This “psychopathy” scale is made up
of 16 MACI items, of which 8 are shared with the Murrie–
Cornell Psychopathy Content scale). The P-16 scale has three
subscales also—egocentricity, callousness, and antisociality.
Both content scales demonstrated predictive validity of gen-
eral and violent recidivism and number of offenses 2 years
later; however, the highest correlations with all three recidi-
vism measures were found with the P-16 total score and two
of its subscales, callousness and antisociality.
The inclusion of the Substance Abuse Proneness scale
underscores the importance of assessing alcohol and drug use
in adolescents. During the MACI’s development phase, this
scale was externally validated with the Problem Oriented
Screening Instrument for Teenagers (POSIT; National Insti-
tute on Drug Abuse, 1991). The MACI’s Substance Abuse
Proneness scale was correlated at r D .64 with the POSIT
test’s Substance Use or Abuse subscale. Grilo, Fehon, Walker,
and Martino (1996) compared MACI profiles of psychiatri-
cally hospitalized adolescents with substance use disorders
and those without. Overall, the group with substance use dis-
orders scored significantly higher on the MACI’s Substance
Abuse Proneness scale as well as the Unruly and Forceful per-
sonality scales, Delinquent Predisposition and Impulsive Pro-
pensity clinical syndrome scales, and Social Insensitivity
expressed concerns scale. Additionally, this group scored
 PREADOLESCENT AND ADOLESCENT PERSONALITY ASSESSMENT
significantly lower on the Submissive, Inhibited, and Introver-
sive personality scales; the Anxious Feelings clinical syn-
drome scale; and the Sexual Discomfort expressed concerns
scale. These results showed an association between substance
abuse problems and externalizing patterns; however, this
likely represents one subtype because adolescents with inter-
nalizing patterns also turn to alcohol and drugs.
The MACI has been the subject of several studies investi-
gating its underlying factor structure. Adkisson, Burdsal,
Dorr, and Morgan (2012) compared different models in 300
psychiatrically hospitalized adolescents and determined that a
three-factor solution best fit the data. The three factors they
extracted—demoralization, acting out, and detached—
accounted for 82% of the total variance. The first factor had
positive loadings (all above .70) on the Borderline Tendency,
Self-Demeaning, Doleful, and Oppositional personality scales;
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and the Eating Dysfunctions, Depressive Affect, and Suicidal
Tendency clinical syndrome scales; and negative loadings
(below ¡.40) on the Egotistic and Conforming personality
scales. The second factor had positive loadings (all above .70)
on the Unruly and Forceful personality scales and the Delin-
quent Predisposition clinical syndrome scale, and negative
loadings (below ¡.50) on the Submissive and Conforming
personality scales and the Anxious Feelings clinical syndrome
scale. Finally, the third factor had positive loadings on the
Introversive and Inhibited personality scales and negative
loadings on the Dramatizing and Egotistic personality scales.
Other studies have employed different statistical procedures
and have found similar factors although not in the same order
regarding explained variance. The most probable explanation
is that researchers have conducted their respective studies
with different adolescent populations, which might have dif-
ferent prevalence rates for the various conditions they study
and the settings they are in. These subjects have included
male (Amato, Cornell, & Fan, 2008; Stefurak, Calhoun, &
Glaser, 2004) and female youth offenders (Stefurak & Cal-
houn, 2007) as well as participants in residential treatment
facilities (Romm, Bockian, & Harvey, 1999) and psychiatric
hospitals (Adkisson et al., 2012). Finally, other researchers
have assessed adolescents from diverse cultural backgrounds
(Blumentritt, Angle, & Brown, 2004; McMahon et al., 2013)
and reported how cultural factors might impact MACI results.
With the turn of the century, Millon turned his attention to a
“new” phase of the life span known as preadolescence. Many
children seemed to be accelerating through childhood, physi-
cally, socially, and emotionally. Yet many found themselves
struggling to meet the challenges before them. At the time,
there were very few self-report inventories for children below
the teenage years. Also, many of these inventories measured
single constructs or, if considered a personality test, they did
not have separate personality scales. Millon saw a niche to be
filled with the Millon Pre-Adolescent Clinical Inventory
(M–PACI; Millon, Tringone, Millon, & Grossman, 2005).
Construction of the M–PACI presented several challenges.
What personality styles have formed to a sufficient degree by
that age? How does one measure those styles in a reliable and
valid manner in this age group? How does one construct items
that children can understand what they are being asked to
report about themselves? The task was an ambitious undertak-
ing and, through Millon’s leadership and expertise, another
member was added to the Millon inventories family.
569
The M–PACI is the only instrument for 9 to 12-year-olds
that identifies common clinical problems within the context of
a preadolescent child’s emerging personality style (Kamp &
Tringone, 2008). The instrument does not assess for personal-
ity disorders and, consistent with Millon’s notion of personal-
ity spectra, the M–PACI’s interpretive reports initially focus
on the adaptive qualities of each personality pattern before
addressing features that might be clinically significant or dis-
ruptive to the child’s intrapersonal or interpersonal develop-
ment and functioning.
The M–PACI consists of 14 scales: 7 emerging personal-
ity patterns and scales and 7 current clinical signs scales.
Among the emerging personality pattern scales are the
“core four”—the interpersonally imbalanced personalities.
They are labeled the submissive, outgoing, confident, and
unruly personalities, and they correspond to the more path-
ological dependent, histrionic, narcissistic, and antisocial
personalities. Two other common emerging personality
patterns, inhibited and conforming, correspond to the avoi-
dant and obsessive–compulsive personalities. The last
scale, the unstable emerging personality pattern, is related
to the borderline personality. Similar to the MACI’s Bor-
derline Tendency scale, elevations on the M–PACI’s
Unstable scale are associated with more significant dis-
tress, which is most evident in mood lability. The seven
current clinical signs scales include Anxiety/Fears, Atten-
tion Deficits, Obsessions/Compulsions, Conduct Problems,
Disruptive Behaviors, Depressive Moods, and Reality Dis-
tortions. Additionally, the M–PACI has a validity indica-
tor, labeled response negativity, which is reported as a
percentile score. Very high scores reflect response patterns
that are both negative and nonspecific, implying a broad
range of problem areas. Very low scores, in contrast,
reflect more positive impressions. It is up to the clinician
to determine what condition or motivation might have led
the child to potentially exaggerate his or her profile in a
negative or positive direction (Tringone, Millon, & Kamp,
2007).
Early research with the M–PACI suggests that some per-
sonality styles appear to be associated with sufficient cop-
ing resources or a sense of resiliency in that they are able
to handle stress or respond to it in an effective manner,
whereas other personality styles wither under the weight of
or potentially perpetuate their troubles (Millon et al., 2005;
Tringone, 2008). For example, the M–PACI’s Confident,
Outgoing, and Conforming scales have all demonstrated
positive correlations with one another, and the first two
scales have had negative correlations with all the other M–
PACI scales. Additionally, these same three scales demon-
strated negative correlations with the Behavior Assessment
System for Children–Self-Report of Personality–Child 8–
11 version (BASC–SRP–C; Reynolds & Kamphaus, 1998)
Clinical Scales and positive correlations with the BASC–
SRP–C’s Adaptive Scales. On the other hand, strong posi-
tive correlations were found between the M–PACI’s Sub-
missive and Inhibited scales with the Anxiety/Fears,
Obsessions/Compulsions, and Depressive Moods scales as
well as the Children’s Depression Index (CDI; Kovacs,
2001) and the Revised Children’s Manifest Anxiety Scale
(Total Score [RCMAS]; Reynolds & Richmond, 2000),
which appear to suggest internalizing tendencies or
 570
vulnerabilities. The M–PACI’s Unruly scale, in contrast,
had strong positive correlations with the Disruptive Behav-
iors and Conduct Problems scales, which is suggestive of
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-
strated positive correlations with all the BASC–SRP–C
Clinical Scales as well as the BASC–SRP–C’s Clinical
Maladjustment and the Emotional Symptoms Index. Also,
this scale had negative correlations with all the BASC–
SRP–C’s Adaptive Scales and the Personal Adjustment
composite in addition to significant positive correlations
with the CDI and the RCMAS. Additionally, the M–
PACI’s Unstable scale has shown very strong positive cor-
relations with all the M–PACI’s Current Clinical Signs
scales, which illustrates a mixture of internalizing (mood)
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and externalizing (behavior) problems (Millon et al.,
2005).
FUTURE DIRECTIONS
With valid and reliable personality scales covering the
entire adolescent and preadolescent age range, research oppor-
tunities abound. Future research should focus on several areas.
One is the ongoing evolution of the instruments themselves.
Colleagues who have been immersed in Millon’s theory for
decades are continuing the ongoing elaboration and refinement
of the instruments. Research empirically establishing the con-
nection between Millon’s theory and the personality styles
measured by the instruments would be most fruitful. For
example, preliminary work has been done to begin to establish
scientific evidence regarding his theory of the relationship
between a parent’s parenting style and the child’s emerging
personality (Dickinson, 2012; Small, 2012). Such research
could ultimately have implications regarding parent training.
Millon’s model incorporates temperament and attachment,
and he theorized about the influence each might have on a
child’s developing personality style in direct and cyclical
ways. Efforts are underway to empirically connect Millon’s
theory to attachment theory; this work has great potential to
elucidate the relationship between early life experiences and
emerging personality patterns. Just as Piaget left a theory that
researchers investigated for decades, so, too, has Millon left
us a roadmap for exploration that will likely continue well
into the 21st century.
FAREWELL
Never one to rest on his laurels, Millon remained intel-
lectually active and productive to his last days. He was
working on various projects and had conducted meetings
to discuss his visions for future directions. He spoke a
phrase that brought meetings to a close: “Onward and
upward.” As a student, this meant certain tasks had been
assigned, and it was time to get them done. He was in pur-
suit of insights and answers; science had to be advanced.
Millon had the vision, the foresight, and the mind to reach
the great heights that he did. He left us a tremendous leg-
acy and, hopefully, his influence will span many genera-
tions forward. Through his many ways of supporting
others, we are confident that he would encourage all in the
TRINGONE AND BOCKIAN
personality assessment field to carry “onward and upward,”
in the name of science, yes, but the ultimate task is to
make a difference in a child’s life.
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