Emerging Personality Disorder in Adolescence Ways of seeing: Ways of being John Berger

1. Emerging Personality Disorder in AdolescenceWays of seeing: Ways of beingJohn Berger Professor Sue Bailey President, Royal College of Psychiatrists BIGSPD 13th Annual Conference, Manchester, 22nd March 2012

2. Historical perspective, public health and individual psychopathology • ‘I would there were no age between ten and three-and-twenty, or that youth would sleep out the rest; for there is nothing in between but getting wenches with child, wronging the ancientry, stealing, fighting.’ (William Shakespeare: A Winter’s Tale, Act III, Scene III) • ‘I am one, my liege Whom the blows and buffets of the world Have so incensed, that I am reckless what I do, to spite the world.’ (William Shakespeare: Macbeth XIII, Scene I)

3. Rights • Mental disorder and children • Context, ecology and resilience • How adult literature can help • Nature-Nurture • Ethical framework for classification, interventions and research • How can we impact on policy matters in this field – WHO, mental health strategy, working at interfaces and transitions

4. The requirement to ensure that all children and young people are provided with mental health care of appropriate quality in response to their needs is emphasized by International human rights treaties. • e.g. Article 24, Convention on the right of the child, and Article 12, International covenant on economic, social and cultural rights. • Both the Marmot Review (2010) and the WHO (2008) have stated that health is a matter of social justice.

5. An ecological framework for understanding child and youth development (Garbarino) Children are embedded in families Families are embedded in neighbourhoods Embedded in neighbourhoods are schools Embedded in families, neighbourhoods and schools are children who will be violent and sexually abusive and who may have mental disorder Families where parents have personality disorder and addictions ‘Think Families’ to enable them to develop adaptive functioning

6. Psychosocial Resilience, pyschosocial care and forensic mental health(Williams, R. & Kemp, V. , 2011) • Triangle of concepts: • Psychosocial resilience is a concept that is in prominent use in the fields relating to disasters, emergencies and adversity; • Psychosocial resilience as a concept in child development, and; • The backgrounds and needs of children and young people who are in contact with youth justice and forensic mental health services, failure to achieve resilience or unable to maintain it in the face of cumulative adversity

7. Children, mental disorders, and conduct disorder (Bailey & Campion, 2012) • In the UK, only 30-40% of children and adolescents who experience clinically significant mental disorder have been offered evidence based interventions at the earliest opportunity for maximum life time benefits (Meltzer et al, 2003, Green et al, 2005). • Parents with children with conduct disorder (Green et al, 2005): • 60% approached a professional source, most commonly a teacher • 28% sought advice from a mental health specialist • 24% sought advice from the special educational services, such as a psychologist

8. Some research suggests that even if all mental disorder was treated with the best available intervention, this would still alleviate less than 30% of the burden of mental disorder (RCPsych report, 2010). • This highlights the importance of promotion of mental health and prevention of mental disorder. • Half of lifetime mental illness, excluding dementia, arises by the age of 14, and three-quarters by the mid-20s (RCPsych report, 2010). • It is a major underlying cause of health risk behavior in 5-16 year olds with: • six-fold higher rates of smoking, • four-fold higher rates of drinking • twelve-fold higher rates of ever using hard drugs • five-fold higher rates of self harm in those with conduct disorder. • Such impacts then continue across the life-course, with higher rates of unemployment, crime, violence and rates of mental disorders (RCPsych report, 2010)

9. Moving beyond the debate • Is personality developed by adolescence? • Is the PD label harmful? Classifications • Challenges getting the formulation right (Adshead, 2012) • Ethics, values based practice and safe-guarding children - anyone under the age of 18 years • What should clinicians be doing in day to day practice?

10. ICD10 Multiaxial DiagnosisWHO (1996) • Axis One Clinical Psychiatric Syndrome • Axis Two Specific Disorders of Psychological Development • Axis Three Intellectual Level • Axis Four Medical Conditions • Axis Five Associated Abnormal Psychosocial Situations 1 Abnormal intrafamilial relationships 2 Mental disorder/deviance or handicap in the child’s primary support group 3 Inadequate or distorted intrafamilial communication 4 Abnormal qualities of upbringing 5 Abnormal immediate environment 6 Acute life events 7 Societal stressors 8 Chronic interpersonal stress associated with school/work 9 Stressful events/situations resulting from the child’s own disorder/disability • Axis Six Global Assessment of Functioning

11. Working group on the classification of mental and behavioural disorders in children and adolescents: International Advisory Group for the revision of ICD10 mental and behavioural disorders • One of the most striking differences between services for adults and services for young people is that the latter frequently involve non-medical as well as medical professionals. • In addition, services for young people involve individuals whose growth and psychological maturation is still continuing. That is so at the level of specialist services as well as primary care.

12. Challenges for those working with adolescents and adults • Identify those most at need of intervention at an early stage • Pathway approach to initial screening • If not been lost in transition and are identified • Case formulation(CF) together with organisational intervention that will seek to enhance engagement with interventions

13. Learning from adultsPIPEs psychologically informed post treatment environments (Initial findings including young adults hopeful) • Key aspects to CF (Sim et al., 2005): • Integrative • Explanatory • Prescriptive • Predictive • Therapist • Together with ‘milestones to recovery’ for in-patients (Logan, Doyle & Holloway, 2010)

14. Readiness conditions required Improving engagement Internal • Cognitive • Affective • Volitional • Behavioural • Identity • External • Circumstances • Location • Opportunity • Resources • Support • Programme timing (Sellen, 2009; McMurran, 2009; Day, 2009; Howells, 2009)

15. Livesey, 2007 • Integrated diagnostic approach – life tasks individuals need to carry out: • The three areas of potential failures: • Achieving a coherent sense of self (intrapersonal failure) • Developing intimacy in interpersonal relationships (interpersonal failure) • Behaving prosocially (social group failure)

16. Tools and testingQualities of a good screening test(Blazer & Hayes, 1998) • Inexpensive • Easy to administer • Minimally uncomfortable to those in whom it is administered • Detects a disorder earlier than would occur if a behavior was severe enough to prompt an intervention • Balances the ability to detect most cases of the disorder with the ability to rule out non-cases • Not subject to variability across different testers or across time in the same tester

17. Learning from adult literature (Duggan et al, 2010) A three-step, top down evaluation model for personality disorder (Livesey) Step 1 Screening for personality disorder Ask a few questions to establish evidence of intrapersonal, interpersonal and social group difficulties No Yes Step 2 Identifying secondary domains Ask more questions to establish which secondary domains are predominantly dysfunctional, to provide ‘extent’ or ‘breadth’ rating Step 3 Trait evaluation Make detailed evaluation for presence of traits and their summation to provide ‘severity’ or ‘depth’ rating

18. The mapping of Livesey’s secondary domains and primary traits and Mulder & Joyce’s four ‘As’ of personality (Duggan, 2010)

19. Using the evaluation schema for the four secondary domains • In expounding the case for an integrated diagnostic system, Duggan et al discuss: • Severity or ‘depth’ of personality disorders • Extent or ‘breadth’ of personality disorder • The concept of ‘episodes of personality disorder’ • Potential utility for clinical prediction and treatment planning

20. Recommended evaluation scheme for the four secondary domains (Duggan, 2010)

21. Positive and negative personality traits: Big Five v. Bad Five (Ashead, 2012) Big Five Found dimensionally in the general community • Extraversion: outgoing personality, sociability • Conscientiousness: seeing things through • Agreeableness: likeability, prosocial stance • Openness to experience • Neuroticism: anxiety and tendency to hyperarousal when stressed • Bad Five • Found mainly in populations with personality disorder diagnoses and associated with significant harm: also dimensional • Avoidance of others and mistrust • Impulsivity and attentional problems • Antisocial attitudes: contempt for social relations, especially need or vulnerability • Rigidity of thought and lack of curiousity • Emotional dysregulation: unpredictable, unmodulated affects when stressed

22. Pros and cons of personality disorder diagnosis(Ashead, 2012; Bailey, 1993, 2006, 2010) Pros • Early diagnosis means early intervention • Improved diagnosis means improved treatment planning and implementation • The personality disorder diagnosis reflects a developmental account of the young person and their experience • Personality disorder is a real disability: we may contribute to stigma and myths if we do not name it when we need to • There are effective treatments for personality disorder • Cons • Tendency of personality disorder diagnoses to ‘stick’ and not be revised as the young person changes • People with personality disorder diagnoses are often refused access to services • The diagnosis is a stigmatising label, and puts the young person at risk of rejection by services and ignorant professionals • The diagnosis does not reflect the trauma histories in young people • It is pointless to make a diagnosis where there is no treatment service

23. History • The concept of psychopathy was first introduced by Cleckley in 1941, emphasizing features of reduced guilt and impaired empathy (Blair and Viding, 2008). • Four decades later, Hare developed a questionnaire measure to identify it. • Twelve years later, the psychopathy construct was extended to childhood (Frick and O’Brien, 1994).

24. Over the past decade, several important and distinctive features have been identified, that separate psychopathy from antisocial behavior as a whole: • Twin studies have shown a high heritability that exceeds that for antisocial behavior unaccompanied by psychopathy (Viding and Jones, 2008). • An RCT trial has shown that there is a worse response to treatment when antisocial behavior is associated with psychopathy (Haws and Dadds, 2005) • A modest degree of continuity between psychopathy and early adolescence and adult psychopathy is assessed some years later using a difference measure (Lynam, Caspi and Moffitt, 2007). • Brain imaging studies in adults and adolescents who exhibited both psychopathy and antisocial behavior have produced striking findings with respect to amygdala dysfunction in the oribito-frontal cortex (Blair and Viding, 2008). • However, it is crucial to recognize that the findings so far lack diagnostic specificity.

25. Research on psychopathic traits suggests that reactive aggression is more strongly linked to negative emotionality, whereas proactive aggression is more closely linked to decreased emotional reactivity, and an increased tendency to exhibit a callous and unemotional response to threat or provocations. As such, ‘child psychopathic’ traits may show different interactions with parenting, for reactive vs. proactive aggression.

26. Are callous unemotional traits – stable across different developmental periods? What is the genetic and neurobiological framework Affective processing Lack of empathy Lack of guilt Insincere charm Neural basis Genetic basis What do we know about children with psychopathic traits

27. What stops a general acceptance of psychopathy? • There are several different questionnaire measures of psychopathy, with only moderate agreement on the different scales, with its uncertainty on the extent to which there should be a reliance on self reporting ratings, or other informal reportive ratings. (Kumsta, R; SanugaBarke, E; Rutter, M, 2012). • It remains to be shown that the relevant features can be reliably and validly assessed clinically. The evidence relies almost entirely on questionnaire scores. • Many, but not all, of the questionnaire measures assume that psychopathy is intrinsically related to antisocial behaviours, both the empirical findings in childhood as well as broader consideration. Skeem, JL and Cook, DJ (2010) cast doubt on this assumption. Many individuals with psychopathy have not shown either oppositional defiant disorder or conduct disorder. • It cannot be assumed that all forms of apparent lack of concern for others reflects psychopathy (Jones, AP; Happie, 2010).

28. Parenting(Yeh, Chen et al., 2011) Reactive and proactive aggression are related to different antecedents. e.g. harsh parenting is more predictive of reactive aggression; Whereas indulgent parenting is more strongly associated with proactive aggression.

29. Child-parent Innovative research(Dadds et al, 2012) • Sample of 4-8 year olds demonstrated that callous and emotional traits (thought to index psychopathy) can be manifest quite early in childhood. • Concept of psychopathy is usually involved in assumption that its origins lie early in life, but it can be measured in early childhood. • A novel ‘love task’ was used as a social ‘press’ for interactive eye gaze. • Fitting with Dadds’ suggestion from earlier research, that lack of attention to the eyes underlies the fear recognition deficits in child psychopathy. • Findings show that the lack of attention to eyes is not associated in any difference in the mother’s interactions with the children. • This implies the deficits lie in the child rather than a parenting feature. • Rutter argues therefore that a good case exists for recognizing psychopathy in childhood, but neither ICD10 nor DSMIV include a diagnosis of psychopathy for any age period. It is alluded to by its inclusion of callous and unemotional traits, in the criteria for ASPD, but this leaves no room for diagnosing antisocial behavior in adult life, when it does not include these features.

30. Some personality disorder assessment tools used in adolescence • Hare Psychopathy Checklist – Youth Version: young people’s version of standard measure of psychopathy (Forth, 2005) • Millon Adolescent Clinical Inventory: developed to be used in teenagers (Millon 2006) • Minnesota Multiphasic Personality Inventory – Adolescence (MMPI-A): an empirically based measure of adolescent psychopathology (Butcher, 2006) • NEO Personality Inventory – Revised: a general measure of Big Five personality traits (Costa, 1992) • CAPP (Cooke, Logan et al, 2012) • SAVRY (2000)

31. Potential new tools • Content validity of the CAPP in juvenile samples (Johnston, Cooke, Logan et al. In Press: 2012). • The authors stress that psychopathic personality traits have been implicated in understanding conduct disordered youth. • The PCL-YV derived from Hare’s PCL-R. • The challenge to use this tool are the levels of concept, developmental appropriateness, ethics and actual utility when used in youth (Johnston & Cooke, 2004). • CAPP as I understand has been developed to capture the construct of psychopathy across several domains of human functioning, and defines psychopathy in terms of personality, instead of mixing personality in with antisocial behavior. • The application of the CAPP to a youth population is of potential great interest.

32. Lennox, 2012, EFCAP • Aim: • To explore the SAVRY protective factors • Look at the post-dictive validity of the protective factors, by examining their association with past behavior • Examine the predictive validity of the SAVRY protective factors to predict desistence from reconviction • Conclusions and clinical implications: • Protective factors are likely to be just as important as risk factors, and should be integrated into risk management • Risk management and intervention: • One protective factor • Build resilience of temperament

33. Adult psychopathy seen as hard to treat (Salekin, 2002; Duggan, 2011: In press). Need evidence base which evaluates current treatment in relation to children with high-CU Traits (Viding, 2007; Yeh & Chen, 2011). Neuro affective profile – suggests need modification of current treatment approaches. Avoid ineffective treatments Avoid punishment approach either boost weak affective response system (Hawes and Dadd, 2007) identify treatment strategies congruent with presenting strengths and weaknesses. Response to reward appears intact address features associated with malleability in relation to parenting style e.g. IQ, gender and timing and nature of interventions. Treatment Efficacy

34. What can we do(Duggan, 2012) • Improve psychological health • Reduce young person's risk of serious harm to others • Develop skills in the workforce to achieve both of these

35. Systematic review of what worksfor interventions in children and adolescents with emerging antisocial personality disorder Summary of recommendations: • Early interventions • Identify vulnerable parents including ante natally • Parents with other mental health problems • Significant drug alcohol problems • Mothers under 18, particularly with history of maltreatment in childhood • Parents with significant previous or current contact with CJS • Whilst avoiding increasing stigma associated with intervention / Labelling as anti social

36. Early interventions for at risk children • Infant mental health programmes • Non maternal care nursery pre 1 year olds • Remove school exclusion • Improve poor parenting • Target multiple risk factors • Interventions for children with conduct problems and associated disorders: ADHD; SLD; LD; and autism • Functional family therapy • Multi systemic therapy • Dialectical behaviour therapy • ‘Support therapy at all transitions continuity’

37. What is known? • Anti-social behavior and callous, unemotional traits have an asymmetrical relationship for both children and adults. • High level of antisocial behavior often occur in the absence of callous, unemotional traits. • High levels of callous, unemotional traits often occur in the presence of antisocial behavior (Hart and Hare, 1997; Fontaine, 2011). • However, several longitudinal studies now suggest that callous, unemotional traits can also occur in the absence of clinical levels of antisocial behavior (Barker et al, 2011; Frick et al, 2003; Row et al, 2010; Fontaine et al, 2011). • In large community samples, callous, unemotional traits only were associated with subclinical levels of antisocial behavior, or later developing antisocial behavior. • Individuals with callous, unemotional traits commonly showed elevated levels of other types of impairment, including: • Poor relationships • Low prosociality • Increased hyperactivity • Callous, unemotional traits may therefore have the potential to serve a useful clinical indicator of psychiatric vulnerability and psychosocial maladjustment, in addition to their potential utility and sub-typing children with conduct disorder.

38. Children with CU traits appear to be characterised by a particular neuro affective profile may reflect strong genetic vulnerability is it “chicken and egg” impact of maltreatment on developing brain. Even if high heritability does not equate with immutability. All subgroups however developed may respond best to modified treatment approaches matching / “personality type to treatment”. Implications for ICD 11.

39. The ‘Challenge’‘Policy the Dance of Change’The Elephant in and out of the Room

40. Good practice anddecision making • Openness and transparency, where the decision making process, including the evidence and arguments on which they rely should be open to full scrutiny • Inclusiveness • Respect • Proportionality • Accountability • Reasonableness and lawfulness • Effectiveness and efficiency • Exercising a duty of care • Whether developing a classification system or running a unit for those with emerging personality disorder in adolescence, a system that is capable of reviewing learning and accepting criticism and complaint

41. ‘Change continues throughout the life cycles, but changes for better or worse are always possible. It is continuing potential for change that means that no time is a person invulnerable to every possible adversity, and at no time is a person impermeable to favourable influence.’ (Bowlby, 1965). • ‘We are made by others, and others are the making of us in every biopsychosocial sense’ (Crossley, 2012). • Contact Professor Sue Bailey at: • patopresident@rcpsych.ac.uk