Severe Conduct Disorder

HIGH RISK?

Juvenile Psychopathy: assessment and intervention

An edited alternative version of this paper was published in the Community Care Magazine 24 November 2005 entitled 'signs of trouble ahead?'

Richard Cross

Often one only needs to press the remote control switch of the television to ‘on’ to find the media commenting on the devastation and harm, which has been caused by children and young people.

This harm is to individuals, animals and property and the comments are frequently around disbelief and confusion as to why the children of our society would do such a thing. This paper attempts to stimulate discussion on the need to implement a strategy of support and intervention for the children who are discussed so frequently in the media, who are responsible for a high percentage of the harm and offences committed within our society (Cross, 2004).

It also attempts to encourage reflection and to move towards a greater understanding of their behaviour and also to try and understand why at the start of a child’s early life, the scales are tipped away from a life of love and trust, to a life of mistrust and hate.

Attachment: a critical time

When looking at this area the concept of attachment can be beneficial in understanding the behaviour of the children described.

I think it is appropriate to pose a question:

‘What makes the normal process that causes attachment and thus a social conscience to occur to be short circuited?You just have to observe a new mother cuddling her baby, you can sense the attunment in the interactions, gazing into each others eyes in an effectional bond that joins them emotionally.

I propose that by understanding the development of an emotionally healthy child and the crucial processes which take place in the first year of life we can help ‘unlock’ some of the clues for when things may go wrong.

During this time the child provided with the formation of ‘social attachments’ and this provides a template for future emotional joining of others in meaningful and healthy relationships.

In all our work with children we all need to have an ability to create a sense of understanding of a child’s behaviour. I believe by being able to ‘look back’ at the early developmental cycle of the child is crucial. This is where the psychodynamic perspective can help, not only to gain a sense of understanding but can give us a point where informed interventions can be proposed.

Much is known about the biological and emotional effects of trauma upon the developing mind and the crucial importance of the primary caregiver in enabling the young child to develop the ability to be reflective and ‘mentalize’ experience (Fonagy, 2002).

Therefore the failing of the attachment process brings difficulties in emotional awareness, perceiving and understanding the emotions of others and difficulties in regulating levels of arousal. This is why I firmly believe that the characteristics of workers attempting to do meaningful work with children need to be able to provide for these deficits by themselves being emotional and self aware of others.

I would therefore encourage everyone involved in the delivery of services to children and young people to explore the great deal that is now know about the possible effects on personality of physical, sexual and emotional abuse.

In my work with adults who would have scored high on the Revised Psychopathy Checklist – the PCL-R (Hare, 1991), although they are perceived as the ‘hard men’ within the correctional system, it may well be that the opposite paradigm is true in that they are vulnerable to psychic trauma. It may well be that they have learned in childhood to create a psychopathic defence as they are too vulnerable to deal with the trauma’s of every day life. For although others, in the same social environment may feel ‘contained and safe’; they may perceive the world as a continuous war zone.

This would then explain why even if people are brought up in supportive environments they can develop traits associated with psychopaths, as it’s the perception of the trauma and that the core pathology may be that of the need to create an ability to lock away and dissociate from there feelings to create an unemotional shell.

This understanding gained from adults who exhibit high risk behaviour can provide an insight in being able to develop more appropriate interventions for children to allow them as individuals to understand themselves better and hopefully make better choices (Cross, 2002).

So I propose for some children the attachment process is derailed, this can be due to a non-nurturing environment. However, I also propose for some, regardless of the quality of the maternal interactions and due to the child’s pathology they may experience trauma due to how they perceive their environment. This would mean the creation of psychic defence structures which would create a tipping of the internal scales towards that of an unemotional mistrust and callousness.

Assessment

From the onset, assessment must be accurate and needs to explore other explanations for the behaviour and co-presenting conditions. I advocate an informed assessment process to enable the psychotherapeutic interventions to be focused on the core needs of the young person e.g. PTSD, Dissociative disorders, ADHD, early signs of personality disorder, etc.

Therefore, I would advocate caution at identifying traits associated with SCD, as all too often when following up diagnoses of SCD made by others, I have found after further exploration that their behaviour has been linked to past experiences of trauma and symptoms consistent with dissociation and acute trauma (Hypervigaliance, arousal etc).

The definition of Severe Conduct Disorder can be described as a marked life-long attitude of being ‘self centred’ taking what one wants, when one wants it without any regard for the feelings and rights of others.

It is a DSM–IV diagnosis, which has 15 symptoms that fall into 4 sets: Aggression to people and animals, Destruction of property, Deceitfulness or theft, Serious violation of rules. Of the 15 symptoms, at least 3 have to have occurred in the past 12 months.

Prevalence is said to be approximately 8% of boys and 3% of girls (Offord, 1991), although the ratio during early childhood of boys to girls is 3:1 by adolescence this disparity is viewed as abating rapidly. It was emphasised that juveniles with SCD can in the latter stages of childhood commit many of the severe crimes seen in society which cause significant harm to others e.g. forced sex, physical cruelty, use of weapon. In early childhood it can present as the child being aggressive, disruptive, unloving, cruel, and defiant to caregivers, educators and others.

Due to these behavioural traits it can lead to peer rejection which can ultimately mean that they distance themselves from a broad based peer group and can set the stage for involvement with deviant peers (Lochman, 2001). This can mean these young people begin to isolate themselves from pro-social peers and this environmental shift can predict delinquency, school dropout, internalising problems, adolescent pregnancy and drug and alcohol use.

A particular group of rejected children who over-estimate their social acceptance may be at particular risk for aggression. Aggression during early toddler years is common and the peak frequency for inflicting physical aggression upon others is at the age of two years – which may be surprising to some (Tremblay, 1996). So aggression is common during the early stages of development and most children use some form of physical aggression, for instance at 18 months of age, 60 % of boys and 30% of girls hit their peers. However, the frequency of this aggression steadily decreases from the age of 2 to 12years. But despite this gradual decline of aggressive behaviour over time a group of 5 –10% of children (SCD) continue with serious levels of aggressive behaviour (Frick, 1998).

The most common co-occurring problems for youth with CD are substance abuse, ADHD, and depression. ADHD has been found in clinical samples diagnosed with CD to present with rates of 65% - 90% (Abikoff, 1992). When present with CD youth have more CD symptoms, early onset of SCD, more violent behaviour and early and greater substance abuse. It is often associated with alcohol and drug use and is this also resistant to treatment. Depression occurs in 15% - 31% of CD youth (Zoccolillo, 1992), which may be exasperated due to interpersonal conflicts with peers and family. Despite this it does not appear to alter the course of CD.

It is this sub group of chronic aggressive children are viewed as being of greatest risk of displaying the most physical violence, delinquency, substance abuse and having school difficulties during adolescence (Nagin, 1999). The adult equivalent of this disorder is severe antisocial personality disorder. This sub group of adult offenders have psychopathic traits (egocentricity, shallow emotions and an absence of empathy, anxiety and guilty). However, it is still not clear if Psychopathy can be reliably assessed in the youth population, but a subgroup of conduct disorder youth exhibit callous unemotional (CU) traits.

The anti social screening device (APSD), which has been adapted from Hare’s Psychopathy Checklist – revised has been used with adolescents to assess CU traits.

The features of severe conduct disorder are:

High rates of aggression,
Age of onset before 10 years old,
Persistent into adulthood,
High rates of co-morbidity
More likely to be solitary or isolated (no intimate relationships, associates but not friends)

Detection of Conduct disorder therefore needs to assess core symptoms and behaviour in relation to age and attempt to gain information from a multiple of sources e.g. parent, teacher, and self-report. These assessments should use structured interviews with parents and youth (Diagnostic Interview Schedule for Children), but can also use behavioural checklists (Behavioural Assessment Scale for children) with age-based norms can be useful.

Risk Factors

The emphasis is on the presence and interplay of both social and biological risk factors in the increasing of the rates for antisocial and violent behaviour.

Identifiable risk factors for Childhood onset of conduct disorder are:

Parental antisocial behaviour
Parental substance abuse
Younger maternal age (what age they had first birth, this would continue onto latter births as a risk factor)
Low IQ (Silverthorn,1999)
Sexual abuse
Early menstrual onset (Moffit et al, 2001)
Limited or lax parental supervision
Harsh discipline (and abuse)

Social risk factors

Low social economic status (SES)
Lower maternal education
Does not vary by race when SES and neighbourhood characteristics are controlled

Overall findings are that risk factors are similar for both genders, but being male is a risk factor in itself and in girls the risk factors also include running away from home (McLaren, 2000) and Child abuse (Leve, in press).

Treatment (Chasidim, 2000; Lesley, 1992; Waslick 1999)

“I’m afraid we won’t be able to do much about prison reform until we start getting a better grade of prisoner” Lester Maddox, during his tenure as the Governor of Georgia

Most evidence-based interventions are not only intensive but require being comprehensive, multi-focussed and multi-disciplinary in delivery. These approaches are viewed as being better at controlling the undesirable behaviour than the actually changing of attitudes or increasing of social values.

There is at present no simple or sure fire fix to the problem of SCD and most interventions need to be in place for months or even years.

Treatments that don’t work and viewed as not meriting government funding are:

Shock treatments
Peer counselling
Excellent delivery of “ordinary” social services (APA. 1997)
Boot camp

Treatments that do work (at least some positive treatment outcome) tend to be

Behavioural
Skills oriented (moral reasoning, problem solving, anger management)
Multi model
Programmes with family based components e.g. parent training, family therapy, couples therapy
Treatment of parent child interactions
Multi-systemic therapy (MST)
Therapeutic Communities

Some promising research is also starting to provide an insight into detectable behaviours that can be identified that may indicate the possible presence of SCD. These have been termed as possible gateways and therefore treatment can be directed towards the following area’s firesetters, graffiti, sexual offenders, sexually abused, and theft.

Therapeutic communities is also a treatment model that is relatively misunderstood but has been delivering promising treatment outcomes for personality disordered offenders (Jones, 2004), traumatised children and young people (Tomlinson, 2004) and have taken up the gauntlet of working of evolving since the work of Bion and Richman in the Northfield experiments during the second world war. I would encourage readers of this paper if they are interested in increasing there knowledge of Therapeutic Community approaches to working with traumatized young people to read the influential writings by Barbara Docker-Drysdale.

The use of medication is understudied but it is generally targeted towards the management of reactive aggression, explosive temper, hostility / negative mood, co morbidity and ADHD. Stimulants (amphetamine, methylphenidate or Ritalin) are seen to help manage ADHD (exacerbates SPCD) and might also reduce aggression.

There are a wide range of initiatives for addressing the problems which have began to provide promising results and demonstrate efficacy at targeting the needs of our young people from pre-school years into adulthood. It must be kept in focus when it comes to allocating resources, that early conduct disorder problems have long lasting effects that can impact on us all in terms of crime, mental health, driving, sexual outcomes, education and employment. With the possible exception of IQ, no other factor that can be present during childhood has as far reaching consequences in terms of development,

Recommendations:

1. Identify the most at risk children preferably before they start school

2. Trial interventions through the wider use of validated intervention programmes (“don’t put all your eggs in the one basket”).

3. Target 1 – 5 % of very young children

4. Interventions with those assessed as highest risk, needs to be intensive and sustained

5. Co-existent psychiatric disorders must be treated and identified,

6. Programmes need to be developed for females based on evidence based protocols as opposed to placing them on programmes developed for males e.g. do better on one-to-one placements where they are isolated from the antisocial peers.

7. Education system needs to provide a safe and controlled stimulating learning environment for the pupils (inclusion not exclusion where at all possible),

8. Therapeutic Communities have demonstrated effective interventions for some time and should be considered as the foundation environment with the ability to contain the work and make sense of the young people’s behaviour.

“If you let young people trash their lives, they will trash your society”

Peter Garrett, singer with Midnight Oil

Richard Cross

References

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