Emerging Research on Psychopathy in Youthful Offenders

1. Emerging Research on Psychopathy in Youthful Offenders MNATSA April 15, 2011 David X. Swenson PhD LP dswenson@css.edu Gerald Henkel-Johnson PsyD LP gjohnson@css.edu The College of St. Scholastica

2. Define the psychopathic personality disorder • Consider cautions in diagnosing youth • Describe callous-unemotional traits in youth • Explore emerging neurological bases of CU traits • Present a speculative model for integrating heredity, neurological, and behavioral antecedents for CU traits and later psychopathic development • Identify treatment options for CU traits

3. What happens to nice kids… …That makes them go bad?

4. Hare characteristics Psychopathy Checklist-Revised– The “Gold Standard” • Glibness/superficial charm (1) • Grandiose sense of self-worth (1) • Pathological lying (1) • Cunning/manipulative (1) • Lack of remorse or guilt (1) • Shallow affect (1) • Callous/lack of empathy (1) • Failure to accept responsibility for own actions (1) • Need for stimulation/proneness to boredom (2) • Parasitic lifestyle (2) • Poor behavioral controls (2) • Early behavior problems (2) • Lack of realistic, long-term plans (2) • Impulsivity (2) • Irresponsibility (2) • Juvenile delinquency (2) • Revocation of conditional release (2) • Promiscuous sexual behavior (T) • Many short-term relationships (T) • Criminal versatility (Hare, 1986) (T) ? Factor 1: Callous emotional and interpersonal detachment; affective impairment Factor 2 (ASP): Chronic and socially deviant antisocial behaviors & lifestyle

5. Meet the psychopath… • Parental alcohol abuse • Paternal abandonment • Exposure to father beating brother to death • Multiple head injuries from parental abuse, fighting, recklessness • Learning disabilities • Introverted & shy as a child; charming as adult • Peer teasing & rejection; relieved by beating them • Compulsive gambling • First murder age 14; tortured & killed animals, claimed 200 people Richard Kuklinsky (The “Iceman”)

6. Oppositional Defiance Conduct Disorder Antisocial/Psychopathy • Glibness/superficial charm (1) • Grandiose sense of self-worth (1) • Failure to accept responsibility for own actions (1) • Pathological lying (1) • Cunning/manipulative (1) • Lack of remorse or guilt (1) • Shallow affect (1) • Callous/lack of empathy (1) • Parasitic lifestyle (2) • Poor behavioral controls (2) • Early behavior problems (2) • Lack of realistic, long-term plans (2) • Impulsivity (2) • Irresponsibility (2) • Need for stimulation/proneness to boredom (2) • Juvenile delinquency (2) • Revocation of conditional release (2) • Promiscuous sexual behavior (T) • Many short-term relationships (T) • Criminal versatility (Hare, 1986) (T) • Bullies, threatens, & intimidates • Initiates physical fights • Used weapon that can cause serious physical harm • Physically cruel to people • Physically cruel to animals • Stolen while confronting victim • Forced sexual activity • Deliberately engaged in fire setting with intentional damage • Deliberately destroyed property • Broken into someone’s house, building, car • Lies to obtain goods or favors or avoid obligations • Stolen nontrivial items without confronting victim • Stays out at night despite parental prohibitions • Run away from home overnight twice while living in parent/surrogate home • Truant from school • Loses temper • Argues with adults • Actively defies or refuses to comply with adults requests or rules • Deliberately annoys people • Blames others for his/hers mistakes • Touchy or easily annoyed • Angry or resentful • Spiteful or vindictive A matter of severity & quality “Unsocialized type”

7. Cautions in Diagnosing Psychopathy in Youth • Adolescence is a period of great developmental changes and some adult psychopathy markers may not apply • Only slightly modified tools used for adults are used for juveniles. • Need for stimulation and impulsivity are stable from childhood to mid-adolescence, tend to increase from mid to late adolescence, and then decline during adulthood. • Lack of goals and irresponsibility are often present since adolescents have limited perspective and capacity for self direction compared to adults. • Teens have restricted sense of long-term consequences which may inflate scores on lack of empathy/callousness and failure to accept responsibility • Fluctuating identity formation during teen years may also affect scoring of grandiose self worth. MacArthur Foundation (nd). Assessing juvenile psychopathy: Developmental and legal implications. http://www.adjj.org/downloads/4536issue_brief_4.pdf

8. Early/adolescent onset • Driven by social processes • Majority (76%) of youth conduct problems • Exaggeration of normal adolescent rebellion • Maintain empathy & avoid peer rejection • Start with serious delinquency • Tends to remit in adulthood • Neuro-developmental processes & impaIrments • Greater stability & severity • Increased family dysfunction, parental separation • Minor aggression escalating with age • Criminal versatility • Peer rejection/ poor social skills • Slow heart rates, poor memory, adaptability Age 8-10  14  18 50% 43% Early Onset Conduct Problems Adolescent Onset Conduct Problems

9. What the research shows: Callous-Unemotional Traits • Low stress: Adult psychopaths and adolescents with high callous-unemotional ratings were found to have low basal cortisol (Cima, Smeets, & Jelicic, 2008; Loney, Butler, Lima, et al. , 2006). • Aggressive: CU youth who exhibit both reactive and proactive aggression show high levels of aggression without provocation (Munoz, Frick, Kimonis, & Aucoin, 2008). • Criminality: They show higher levels of instrumental and premeditated aggression during adolescence and are at higher risk for antisocial and criminal outcomes as adults (Moffitt, Caspi, Harrington et al., 2002) • Low Parenting Response: CU children are less influenced by parenting than non-CU children (Frick, et al., 2003) • Mood & Neurological: Show more dispositional vulnerabilities (for example, temperament risk factors and neurocognitive deficits) than those in the adolescent-onset group (Dandreaux& Frick, 2009) • ADHD: Many show co-occurring ADHD (Abikoff & Klein, 1992) • Very Early Onset: CU traits can be identified in children as early as age 3 or 4 (Dadds, Fraser, Frost, et al., 2005) • Stability: Traits are stable from late childhood to adolescence as measured by self report and parent report (Munoz & Frick, 2007) • Chronic: Traits are more related to serious offending, severe violence, poor treatment progress, shorter time to recidivism

10. Comparison of psychopathy in adults & youth Blair, J., Mitchell, D., & Blair, K. The psychopath: Emotion and the brain. Malden, MA: Blackwell

11. Inventory of Callous Unemotional Traits

12. Psychopathic Checklist– Youth Version (PCL-YV) Impression management: conforms to social desirability, presents in a good light, superficially charming Grandiose self image: dominating, opinionated, inflated view of own ability Stimulation-seeking: needs novelty, excitement, prone to boredom, risk taking behavior Pathological lying: pervasive lying, lies readily, easily and obviously Manipulation: deceitful, manipulates, dishonest or fraudulent schemes than can be criminal Lack of remorse: no guilt, lacks concern about impact of behavior, justifies and rationalize abuse of others Shallow affect: only superficial bonds with others, feigns emotions Callous or lacking empathy: views others as objects, no appreciation of needs & feelings of others Parasitic orientation: exploits others, lives at expense of friends and family, gets other to do his schoolwork using threats Poor anger control: hotheaded, easily offended and acts aggressively, easily provoked to violence Impersonal sexual behavior: indiscriminate or multiple casual sexual partners , uses coercion or threats Early behavior problems: lying, theft, fire-setting before age 10 Lacks goals: no interest or understanding of need for education, lives day to day, unrealistic future aspirations Impulsivity: acts out frequently, quits school, leaves home on whim, acts on spur of moment, not consider consequences of impulsive acts Irresponsibility: habitually fails to honor obligations or debts, reckless behavior at school and home Failure to accept responsibility: blames others for his problems, claims he was “set up.” Unstable interpersonal relationships: turbulent extrafamily relationships, lacks commitment and loyalty Serious criminal behavior: multiple charges or convictions for criminal activity Serious violations of conditional release: two or more escapes from security or breaches of probation Criminal versatility: engages in at least six different categories of offending behavior

13. Differences between C-U and Impulsive (ADHD) Youth Dolan, M. (2008). Neurobiological Disturbances in Callous-Unemotional Youths. American Journal of Psychiatry, 165, 668- 670.

14. Conduct Disordered vs. Callous-Unemotional Youth (Frick, 2006)

15. Aggression Differences

16. Increased Frontal Lobe Grey Matter (DeBrito et al, 2009) • Callous-Unemotional traits in boys actually had increased grey matter in frontal lobes, as compared to typically developing boys. • This seems to indicate a delay in maturation in decision-making, empathy, and morality.

17. Stability of CU Traits • Relatively stable from late childhood to early adolescence • This level of stability is much higher than is typically reported for parent ratings of other aspects of children’s adjustment • High rates of stability for parent and self-report ratings of CU traits over a nine year period but lower (but still significant) levels of stability for teacher • Self-reported CU traits were relatively stable from late adolescence (age 17) into early adulthood (age 24) • Measures of CU traits assessed in childhood are significantly associated with measures of psychopathy in adulthood

18. Deceitfulness and recklessness have high temporal stability. • Natural changes in personality over time e.g. people become less neurotic, anxious over time.

19. CU Traits and Aggression • CU correlated with aggressive, antisocial, etc. • Narcissism and Impulsivity have even stronger associations with behavior problems (Frick & White, 2008) • CU associated though with more severely aggressive youth • Heritability factors – what are the parents like?

20. Born to be wild? • In 1972 1,795 3 year-olds were enrolled in a longitudinal study of trait development in psychopathy. Toddlers were rated for disinhibited temperament, stimulation seeking and fearlessness. Physiological reactions by skin conductance startle response was also monitored. • 25 years later 335 adults were reassessed using a self-report version of the PCL-R • Adults with higher psychopathy scores had marked differences as 3 year-olds: less fearful/inhibited, more stimulus seeking, and reduced sensitivity to negative stimuli (longer skin-conductance half recovery times). Glenn, A. L., Raine, A. Venables, V. H., & Mednick, S. (2009). Early temperamental and psychophysiological precursors of adult psychopathic personality. Personality Disorders: Theory, Research, and Treatment, S(1), 46-60.

21. What are these people feeling?

23. Mirror neurons: Monkey see, monkey do • Newborns as young as 72 hours old can imitate some facial expressions • A mirror neuron is a neuron which fires both when an animal performs an action and when the animal observes the same action performed by another • mirror neurons have been found in the premotor cortex (motor behavior) and the inferior parietal cortex (distinguishing self/other) • These appear to be involved in understanding intentions of others, empathy, predicting actions of others, and social bonding • Such empathy usually prevents us from causing discomfort to others (Blair’s theory of Violence Inhibition Mechanism)

24. Faulty Facial Processing by adult psychopaths • fMRI tested 9 normal and 6 criminals in their response to joyful & neutral, and fearful & neutral facial expressions • Normals showed reaction to distressed sad and fearful faces, while psychopaths showed even less activity than when they viewed neutral faces • Antisocials misinterpret social cues & attribute hostile intentions • Impairment in deep emotional relationships that come from reading emotion cues • Less communication between amygdala and ventromedial prefrontal cortex impairs processing of fear and moral reasoning • Conclusion: the neural pathways that are supposed to process human emotion are either non-functional or are processed differently– psychopaths don’t identify with the emotional stress of their victims Deeley Q, Daly E, Surguladze S, Tunstall N, Mezey G, Beer D, Ambikapathy A, Robertson D, Giampietro V, Brammer MJ, Clarke A, Dowsett J, Fahy T, Phillips M and Murphy DG (2006). Facial emotion processing in criminal psychopathy. Preliminary functional magnetic resonance imaging study. British Journal of Psychiatry, 189, 533-539.

25. “I gotta feeling”…or not! • The amygdala is involved in aversive conditioning and instrumental learning (e.g., learn goodness & badness of actions), and passive avoidance learning (stopping actions when they will result in punishment) • Also involved in fearful and sad facial expressions • fMRI’s show reduced amygdala volume in psychopathic functioning • The ventromedial PFC & medial OFC gives and receives projections from the amygdala & are involved in instrumental learning • Social convention, care-based morality, disgust-based morality and fairness/justice are impaired

26. Cavum septum pallucidum • The striatum area functions as a partial gatekeeper for impulsivity • Persons with a large midline gap (nearly 10% larger than normal) have significantly higher levels of antisocialpersonality, psychopathy, arrests and convictions comparedwith controls; higher in autism and meth addicts • This is one of the last areas to fully develop anatomically, and this mid-line immaturity shows up in a lot of clinically diagnosed conditions, like fetal alcohol. • This area is often hungry for dopamine, and is related to psychopath’s stimulus seeking and hypersensitivity to rewards • This area may reflect limited introspective & insight ability

27. “That was funny!”: Bullies enjoy the pain of others • Aggressive youth were shown clips of a pianist having fingers pinched by closing the piano lid on them • Areas related to processing pain were activated, but… • So were the amygdala and ventral striatum (reward centers) • Unlike unaggressive youth, aggressives did not activate medial prefrontal or temporoparietaljunction associated with self regulation (impulse control) • Youth without aggression problems did not show the same activation, but instead it evoked empathy http://huehueteotl.wordpress.com/category/science/neuroscience/

28. Lykken study startle The amygdala is 17% smaller in psychopaths Normal people show fear, startle, and avoidance reactions to painful stimuli– psychopaths don’t

29. Frontal areas not engaged that would reflect meaningful association Many areas of the brain are activated Visual area activated with viewing words Right hemisphere processes negative emotion http://www.youtube.com/watch?v=oaTfdKYbudk&feature=related

30. Non-reactivity to Emotional Stimulation Antisocials react to horrific pictures the same as they do to neutral pictures They process emotional information as if it was neutral information

31. The brain during empathy response fMRI scan shows normal brain activity with empathy on left; psychopathic low activity on right Participants were asked to view pictures of unpleasant scenes and people experiencing distress Department of Clinical and Cognitive Neuroscience, University of Heidelberg

32. The Brain and Ethical Reasoning: The lesser of two evils “You are standing next to a switch in a trolley track and you notice that a runaway trolley is about to hit a group of five people who are unaware of their danger. However, if you switch the track, the trolley will hit only one person. What do you do?”

33. “You are standing on a bridge over a trolley track beside a single person. Again you notice that the runaway trolley is headed toward five unaware people. Do you push the single person onto the track to stop the trolley?”

34. Brain injury & moral choices: “Willingness to violate moral choices of any type” Ventromedial Cortex Koenigs, M., Young, L., Adolphs, R., Tranel, D., Cushman, F., Hauser, M., & Damasio, A. April 19, 2007). Damage to the prefrontal cortex increases utilitarian moral judgments. Nature. Glenn, A. L., Lyer, R., Graham, J., Koleva, S., & Haidt, J. (2009). Are all types of morality compromised in psychopathy? Journal of Personality Disorders, 23(4), 384-398.

35. Low oxytocin levels • Low feelings of trust, sharing & generosity • Narcissism Stress • Low skin conductance Prenatal retinoid toxicity? • High daring & stimulation seeking • Low anxiety & fear • Low cortisol (low stress response) • Low resting heart rate & arousal • Low harm avoidance • Not anticipate consequences • Low capacity for fear, aversive conditioning (or punishment insensitivity • High dopamine production • Colder more predatory violence 50-80% Genetic inheritance (5-HTTLPR gene, s-allele, MAOAgenotypes, ?) • Low serotonin • High reactive & proactive aggression • Increased gray matter in the anterior cingulate cortex • Co-morbid ADHD (75%) • Impulsiveness • Fewer mirror cells • Lack conscience (don’t read distress, no empathy, poor response to punishment) • Underactive amygdala • Deficit in ethical & moral reasoning & social responsibility • Reduced reaction to emotional words & images • Diminished avoidance of aversive stimuli • Absent empathy, guilt, remorse • Underdeveloped ventro medial prefrontal and orbito frontal cortex • Limited facial recognition • Diminished emotional memory • Low perspective taking • Poor behavioral inhibition

36. Less easily-socialized youth require more competent parenting to avoid personality disorders • Neglect • Conflict • Parental deviance • Family disruption

37. Development of behavior disorders in youth • Environmental • pop. density • poor housing • mobile residents • discrimination • media violence • cultural norms • no support svc. • discrimination • crime rate • Infancy • Prematurity • low birth weight • brain injury • attachment • hyperreactive • “colicky” • unhealthy • disability • pain • multiple placements • Peers • delinquent/deviant peers • antisocial sibs • bullying • rejection by norm group • attention/recognition • belonging • act out • revenge PROBABLE OFFENSE • Family • cohesion • flexibility • poor boundaries • inconsistent discipline • poor supervision • marital relationship • handle emotions • poor role modeling • criminality • physical, emotional, • sexual abuse • explicit sexuality • disorganization • cold, rejecting • large family • father absence • long unemployment • Pre-family • poverty • single • unwanted • MI (depression) • AODA • teen/immature • abused • antisocial • divorce • assortative mating • transgenerational problems • Legal/Offense • Hx of violence • Type/frequency/severity • Non-violent offending • Early onset of violence • Past supervision failure • Domestic violence • Escalating pattern • Victim age vulnerability • Deviant arousal • Capacity • Low IQ • LD • ADHD • FAS/FAE • Bipolar • PDD • Brain injury

38. The early solution…lobotomy! • In 1966 12 year-old Howard Dully became the youngest recipient of the icepick transorbital lobotomy for: “being unbelievably defiant…objects going to bed…daydreaming… and says ‘I don’t know.’” • Lobotomy developer, Dr. Walter Freeman travelled the US in his Lobotomobile conducting up to 2500 of the 10 minute procedures in 23 states from 1936-1967

39. Letter from a parent… Most of America 's populace think it improper to spank children, so I have tried other methods to control my kids when they have one of "those moments."One that I found effective is for me to just take the child for a car ride and talk. They usually calm down and stop misbehaving after our car ride together. I've included a photo below of one of my sessions with my son, in case you would like to use the technique. Sincerely,    A Friend  

40. Requirements of Tx Amenability: Typical Requirements of Treatment • Ability to Relate • able to engage with therapist • self disclosure of historical information • trusts therapist • Timeliness • willing to attend treatment • regular attendance • timely attendance • remains during session • Socialization • identification • empathy • guilt • shame • embarrassment • remorse • Personal Acknowledgement • acknowledge problem • shows concern about the problem • admission of guilt • take personal responsibility • admits impact on others • External response • compliments • encouragement & support • impact on others • conforms to rules • responds to direction • able to be distracted or redirected • responds to discipline & consequences • Goal Orientation • can formulate goals • can formulate specific behavioral objectives • prioritize goals • attaches value to goals • Disclosure • discloses personal information • discloses sensitive information • discloses previously unknown information • expression of feelings • expression of thoughts, beliefs, attitudes • Persistence • accepts treatment homework assignments • completes homework assignments • comes prepared for sessions • reports homework assignments • persistence in examining difficult issues

41. Traditional treatment difficulties with psychopaths • Low motivation to change (low anxiety) • Rarely initiate treatment (CD Tx) • Noncompliance with requirements & rules • Low empathy, remorse, guilt • Highly impulsive, risk-taking & reckless • Lack of insight into affective state • Avoidance of personal responsibility • Superficial relationships; lack therapeutic alliance • Noncompliance and disruption of others’ Tx • Tend to focus on primary goal & ignore peripheral & cost/benefit reasoning • Noncompliant with or abuse medication • Less reactive to aversion & punishment • Lack of understanding of antecedents of behavior make relapse prevention strategies difficult • Cannot trust self-report, deceptive, manipulative

42. Other Treatment Issues • Overall, show more “bumps in the road” of treatment, but don’t assume this means no positive outcomes. • Need to improve on emotional distress (sad and fearful) recognition, not necessarily on positive emotion recognition. • Not as responsive to punishment, tend to emphasize the positive/rewarding aspects of aggressive behavior. • While • More effective parenting does reduce CU traits (Frick et al, 2003). • Don’t typically “just become” CU later in high school. • Need more treatment models

43. Corrective Thinking Needed?

44. Effectiveness of corrective thinking Effectiveness of Corrective Thinking • High risk clients • 66% reduction in crime for those who completed the program. • 48% of all clients pursued no new crime. • 33% reduction in crime for those who entered but did not complete. • 29.4% exhibited a decrease in crime. • 15.6% exhibited an increase in crime. • 6.4% showed no change. • Average number of criminal charges: • Reduced by slightly over 50% for all clients who entered the program. • Reduced approximately 66% for those who completed the program. • Reduced by approximately 33% among clients terminated before completion. • Reduced 79.17% for those who completed and had no previous arrests. • Reduced 36.36% for those who terminated prior to completion with no prior arrests. Truthought's Corrective Thinking Treatment Model includes four studies done by University of Wisconsin, US Department of Justice National Institute on Corrections, US Department of Justice Bureau of Justice Assistance (1988-1993)

45. Intervention Programs for CU Youth • Early assessment & intervention; Facial recognition training, especially distress and fear • The term “psychopathy” does affect decision-making by professionals but it does not have any more negative effects than using the term “conduct disorder” • Families and Schools Together (FAST): early childhood family support groups; Emotion talk with attachment figures • Multisystemic Therapy & Case management home visits to support family functioning • Low-fear children don’t respond to the type of socialization (gentle, non-power, assertive discipline) that leads to conscience development in more fearful children (Dolan, 2004) (e.g., style has less influence than heredity) • Include safety plans as part of the treatment plan http://www.promoteprevent.org/Publications/EBI-factsheets/FAST.pdf

46. Intervention Programs for CU Youth (cont’d) • Parent training for effective behavior management skills: works for rewards but not discipline (e.g., time-outs); Focus on rewarding positive behaviors rather than punish negative (4:1 ratio) • Cognitive behavior Tx for emotional regulation and anger control (combine with stimulant medication for comorbid ADHD) • Teacher use of effective behavior management skills & academic tutoring; time-outs are less effective • Close proximity & direct eye contact helps focus on salient aspects of the situation rather than inappropriate goals (do not use with “hot” kids) • Aggression Replacement Training: anger control, social skill competence & moral reasoning • When ADHD is co-occurring, behavioral Tx and stimulant medication is more effective but still not within normal range

47. Other Treatment Issues • Overall, show more “bumps in the road” of treatment, but don’t assume this means no positive outcomes. • Need to improve on emotional distress (sad and fearful) recognition, not necessarily on positive emotion recognition. • Not as responsive to punishment, tend to emphasize the positive/rewarding aspects of aggressive behavior. • More effective parenting does reduce CU traits (Frick et al, 2003). • Don’t typically “just become” CU later in high school. • Need more treatment models

48. Oxytocin: Love potion #9? • Plays a key role in complex emotional and social behaviors, such as attachment, social recognition and aggression, & recall of positive social memories • People under stress (especially women) can activate “tending and befriending” response of reaching out to others • Dose improves ability for facial recognition (Fehr & Klaver) & identification of emotional content in speech (DeAngelis, 2008) • Related to feelings of trust & generosity • May have benefit for social anxiety and social fears in autism and can moderate aggression “I just made this for you. It’s oxytocin!”

49. Decompression Therapy • Mendota Wisconsin program with psychopathic juveniles uses individual therapy focuses on reducing the cycle of punishing for bad behavior generating more bad behavior and punishment. • There are twice the number of staff per client compared to other facilities, and are are trained to give priority to continuous intensive treatment in how they respond to disruptive and aggressive behavior. • The MJTC program provides school services and group therapy focused on anger management (Anger Replacement Therapy), improved social skills and problem solving, and issues of substance abuse and sexual offenses. • Youth typically have several individual counseling sessions each week with a psychologist, psychiatrist, or social worker. Kiehl, K. A., & Buckholtz, J. W. (September/October, 2010). Inside the mind of a psychopath. Scientific American Mind, 22-29; Van Rybroek, G. J. (January, 2010). Mendota Juvenile Treatment Center Program. http://www.nrepp.samhsa.gov/ ViewIntervention.aspx?id=38

50. Decompression Therapy, cont’d • A cornerstone of the intervention is the Today-Tomorrow Program, a behavioral point system that closely monitors the youth’s behavior and is highly responsive to changes in his behavior. Adolescents earn privileges following relatively short periods of positive behavior. • Average length of time in treatment at MJTC ranged from 45 to 83 weeks. • MJTC treatment contributed to longer periods of time in the community before the first offense (p < .05 for misdemeanor offenses and p < .005 for felony offenses, violent offenses, and violent felony offenses). • 150 youth treated were 50% less likely to engage in violent crime after Tx compared to a control group at regular juvenile correction facilities • In the 4 years after release the control group killed 14 people while the treated juveniles killed none. • Economically, for every $10,000 spent on Tx saved $70,000 that would have been required to maintain them during incarceration Group Discount Therapy