Sociopathic Behavior in Children David C. Rettew, M.D.

Sociopathic Behavior in Children
David C. Rettew, M.D.
Associate Professor of Psychiatry and Pediatrics
Director, Pediatric Psychiatry Clinic
Training Director, Child Psychiatry Fellowship
University of Vermont, College of Medicine
Disclosures of Potential Conflicts
Source
Consultant
Advisory
Board
Stock or
Equity
>$10,000
Speakers’
Bureau
Research
Support
Honorarium
for this talk or
meeting
NONE
Funding from NIMH (K08 MH069562) and the
University of Vermont College of Medicine
Physician Scientist Award
Will be discussing off-label uses of medications
Expenses
related to this
talk or
meeting
Objectives
• Review concepts and definition of aggression
and sociopathy as they relate to children
• Discuss new basic neurobiology and features of
childhood sociopathy
• Outline strategies for treatment
So
Angry
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Vio
Delinquent
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a
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s
f
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D
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Opposi
A
tional
Callous-Unemotional
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t
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Conduct Disorder
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y
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P
Police: Juveniles laughed after setting 15-year-old on fire
15-year-old suffered second-degree burns over 80 percent of his body
Three juveniles arrested Monday night, 2 others arrested Tuesday
Police say one suspect apparently took bike to settle money dispute
They say alleged victim set on fire after he reported theft and suspect was
arrested
Key Statistics 2007-2008
(National Center for Education Statistics)
• 55.7 million kids school
K-12
• 21 homicides and 5
suicides
• 1.5 million nonfatal
crimes
Total nonfatal acts
Normal Aggression?
• Typical peak at 3 years old – only 28% display
little or no aggression (Tremblay 2004)
• Naturally selected trait that may be somewhat
outdated
• English philosophers considered the restraints
of unsanctioned aggression to be the only
justification to intrude on personal liberties
Definitions
• Aggression: Overt behavior that involves threat
or action that potentially or actually causes pain
• Violence: Physically or psychologically harmful
human aggression that involves the threat or use
of force
• Psychopathy: Lack of empathy, arrogance,
manipulative, superficial
• Sociopathy: Individuals with group values towards
rule-breaking behavior (eg gangs)
• Diagnoses: Oppositional Defiant Disorder,
Conduct Disorder, Antisocial Personality Disorder
Psychiatric Diagnoses Associated with
Aggressive Behavior
• Oppositional Defiant Disorder
• Conduct Disorder
• Antisocial Personality
Disorder (over age 18)
• Attention-Deficit/Hyperactivity
Disorder
• Mental Retardation
• Pervasive Developmental
Disorder (Autism)
• Intermittent Explosive
Disorder
• Bipolar Disorder
• Reactive Attachment
Disorder
• Post Traumatic Stress
Disorder
• Borderline Personality
Disorder
• Psychotic Disorders
• Other disorders: head injury,
epilepsy, dementia
DSM-IV Diagnoses
• 313.81 Oppositional Defiant Disorder (ODD)
– Negativistic, hostile, and defiant behavior including losing
temper, refusing to comply, often angry, spiteful
– Diagnosis generally given to younger children
• 312.8 Conduct Disorder
– Repetitive and persistent behavior that violates rights of others or
societal norms including aggression to people and animals,
destruction of property, stealing/theft, running away, truancy
• 301.7 Antisocial Personality Disorder
– Pervasive pattern of violation of rights of others with unlawful
behavior, deceitfulness, aggression, recklessness,
irresponsibility, and lack of remorse
– Must be over 18 years old for diagnosis with evidence of conduct
disorder before age 15
Types of Aggression
•
•
•
•
•
Sanctioned versus Nonsanctioned
Hyper versus Hypoarousal
Overt versus Covert
Direct versus Relational (Ligthart et al., 2005)
Proactive versus Reactive
– Most commonly used dichotomy but fails to account
for combined proactive/reactive behavior of many
aggressive exchanges
– BUT proactive aggression usually exists with
reactive aggression
Reactive Aggression
•
•
•
•
•
More impulsivity
More anxiety/neuroticism
Lower verbal intelligence
Higher rates of dysfunctional parenting
Higher threat appraisal
Think anxiety driving aggression when…
Child Behavior Checklist
• Aggression is
more reactive
• Predictable in
certain
environments
• Rating scales
show increase of
both disruptive
behavior and
mood/anxiety
Three Dimensions of Psycopathy
• Callous-Unemotional traits
• Arrogant and deceitful personal
style
• Impulsivity, irresponsibility and
proneness to boredom
Callous-Unemotional Traits
• Construct developed by Paul Frick
• Lack of guilt and empathy along with manipulation of
others
• Low autonomic arousal
• Designates a more severe, stable and treatment
refractory course
• Genetic effects about 41-42% from twin studies with
very little shared environmental effect
• Associated with deficits in processing of negative
emotions
Callous-Unemotional Traits
• Less sensitive to punishment cues and high
positive expectations
• High novelty seeking, low anxiety
• Possible reduced amygdala activation in affective
memory tasks
• May respond best to a tougher more obedience
oriented parenting style although others have
argued the opposite
• Association between hypoarousal and antisocial
behavior higher among those in higher SES and
intact families
Inventory of
CallousUnemotional
Traits
Epidemiology
• Psychopathy in about 1% of general population (15%
and 7.5% of incarcerated men and woman)
• Conduct disorder rate of 1.5 to 3.4% in community
studies
–
–
–
–
–
More represented in lower SES groups
Onset peaks in early adolescence
Male to female as high as 5:1 depending on age
More common in urban settings
Development to Antisocial Personality Disorder up to 40%
• Oppositional Defiant Disorder up to 16%
ODD Phenomenology
• “Onset” in preschool or school-age
• More common in boys during preschool years
but then becomes more equal
• More common in low SES households
• Research rarely with ODD in isolation and rather
ADHD/ODD or ODD/CD
Aggression Sex Differences – Mother Report
mean raw score
14
12
10
8
6
4
2
0
age 3
age 5
boys
Slide courtesy of J Hudziak, MD
age 7
girls
age 10 age 12
Aggression Sex Differences – Teacher Report
mean raw score
7
6
5
4
3
2
1
0
age 5
age 7
boys
Slide courtesy of J Hudziak, MD
age 10
girls
age 12
Demographic Variables Associated with
Aggression
• Male Sex
– 90% of those arrested for
murder are men
– 99% of serial killers are men
• Race
– Effect disappears when
controlling for education and
socioeconomic status
• Socioeconomic Status and
Stress
– May also be related to status
within group
• Substance Use
• Maternal smoking and other
fetal exposures
• Delivery complications
• Childhood lead exposure
• Trauma and domestic violence
• Cognitive threat appraisal
• Lower IQ
• Peer group
• Temperament (novelty seeking,
lower regulation)
• Larger body size
• Disorganized attachment
• Autonomic hypoarousal
Effect of Media on Childhood Violence
• Strong evidence for
association between amount
and content of TV/video games
and later aggression
• Causality has been more
difficult to demonstrate
conclusively
• Effect may be different for
different people (more
aggressive children are
affected more)
Parenting Aspects
•
•
•
•
•
Coercive family processes
Lack of supervision
Lack of positive involvement
Inconsistent discipline
Outright abuse
Mean Raw Score
Mean Aggressive Syndrome
Averaged Across Cohorts
10
8
6
Males
Females
4
2
0
4/5
6/7
8/9
10/11 12/13 14/15 16/17
18
Age
Figure appears in Stanger, C., Achenbach, T.M., & Verhulst, F.C. (1997). Accelerated longitudinal
comparisons of aggressive versus delinquent behavior syndromes. Development and
Psychopathology, 9, 43-58.
Mean Raw Score
Mean Delinquent Syndrome
Averaged Across Cohorts
2
1.5
Males
Females
1
0.5
0
4/5
6/7
8/9
10/11 12/13 14/15 16/17
18
Age
Figure appears in Stanger, C., Achenbach, T.M., & Verhulst, F.C. (1997). Accelerated longitudinal
comparisons of aggressive versus delinquent behavior syndromes. Development and
Psychopathology, 9, 43-58.
Aggression
Life Course of Aggression
10
9
8
7
6
5
4
3
2
1
0
Childhood Limited
Adolescent Limited
Childhood Persistent
Adolescent Persistent
Adult Onset
5
10
15
20
25
30
Age
Note: Expansion of “life-course-persistent” versus “adolescence-limited” groups
found by Moffitt (Psychol Review 1993)
ODD Course
•
•
•
•
•
Begins in late preschool or early school-age
About 2/3rds remit with good treatment
Up to 30% develop Conduct Disorder
Early onset bad prognostic sign
Perhaps 10% to develop Antisocial Personality
Disorder
Neuroanatomy of Aggression
Hypothalamic Attack Area
Cortex
Executive Function
Impulse Control
Amygdala
Threat processing and
memory
Brainstem
Arousal to threat
Neuroimaging Studies in Psychopathy
• Less activation of frontotemporal lobes
• Smaller hippocampus (acquisition of
fear learning)
Physiological Studies
• Autonomic hypoarousal and hyposensitivity
especially when studying children with callousunemotional symptoms
• Not good evidence regarding abnormal male
hormones
Brain Chemistry
• Serotonin: Lower levels and impulsive
aggression
• Neurepinephrine/cortisol: Fight of flight
• Dopamine: Permissive role in aggression and
involved in reward processing
• GABA: Anxiety
• Testosterone: Dominance; inconsistent findings
which may be related to development
Genetics
• No aggression gene
• Multiple genes with each with smaller effects
• Many genes related to formation and
metabolism of brain chemicals
Genetics of Aggression
Shared
Envir
20%
Unshared
Envir
20%
Additive
Genetics
60%
Genetics
Shared E
Unshared E
Hudziak, van Beijsterveld, Bartels, Rietveld, Rettew, Derks, Boomsma, Twin Research, 2003
Genes and Environments
Study of Swedish Adoptees
Risk
Chance of Criminality
No history in biological or
adoptive family
Adoptive family only
2.9%
Birth family only
12.1%
Both birth and adoptive
40%
6.7%
From Victoroff, Human Aggression, 2009
Gene Environment Interplay
• Reading found to modify
genetic effect of aggression
in boys (Johnson et al.,
2007)
• Effect of MOA gene on
aggression present only in
disadvantaged families
(Foley et al., 2004)
• Heritability of aggression in
children decreases from
52% in low conflict families
to 37% in high conflict
families (Hudziak)
The Harry Potter effect!
The Harry Potter effect!
-r
Aggression Treatment
Make aggression……
• Irrelevant – change antecedents by avoiding
triggers, reducing frustration, giving attention to
positive behavior
• Ineffective – change consequences by avoiding
gains of aggression and rewarding alternatives
• Inefficient – teach new skills that can accomplish
goals such as improving verbal communication
and providing space to cool off
From Bader and Jensen, 2007
Treatment of Aggression
Emotion
Intervention for the emotion
Expression
Intervention for the expression
What Doesn’t Work
• Boot camp coercive treatment not
found to be effective and may
make things worse
Comprehensive Treatment
• Parent Management Training – using positive
reinforcement, appropriate discipline, consistency
• Cognitive Behavioral Therapy
– Problem-Solving Skills Training
– Cognitive restructuring (ie perceiving less threat)
– Relaxation and mindfulness
•
•
•
•
•
•
Social Skills Programs
Medications
Mentorship and structure
Alternate positive experiences
Social supports
Environmental Changes – video games, sleep, nutrition
Parent Management Programs
Publications for Parents
“Anger Management”
• Loose term applied to program (often group
based) designed to help individuals control
responses to anger
• Often mandated by court without full knowledge
• Results mixed and may not be as helpful in
those with more extreme aggression (ie those
who are told to do it)
• Components can include relaxation, visual
exposure, role playing, cognitive restucturing
Multisystemic Therapy
• Best supported treatment
• Home-based
• Studies of its usefulness often very extensive
(daily contact, many hours)
• Components include intensive case
management, skill training, mentorship,
treatment of ADHD, school interventions)
• Time limited – about 4 months
Medications Used for Aggression
• Stimulants: Concerta, Ritalin, Adderall
• Atomoxetine (Strattera)
• Alpha agonists: clonidine or guanfacine (Tenex,
Intuniv)
• Antidepressants: fluoxetine (Prozac), sertraline (Zoloft)
• Mood Stabilizers: lithium, valproic acid (Depakote),
lamotragine (Lamictil)
• Antipsychotics: risperidone, aripiprazole (Abilify),
quetiapine (Seroquel)
Treatment by Type
• Reactive Aggression: teaching skills (e.g.
Collaborative Problem Solving), identifying
triggers, reducing anxiety
• Proactive Aggression: Changing rewards
structure, influences, and environment
What you can do
• Frame child aggressive behavior like any other
medical problem at school
• Advocate that school has an organized
approach to sociopathic behavior at the school
• Encourage families who need it to get help (both
perpetrators and victims)
Resources
• Promising and Proven Programs on Youth Violence Prevention
(Office of Justice
http://www.ojp.usdoj.gov/programs/yvp_programs.htm)
• National Youth Violence Prevention
(http://www.safeyouth.org/scripts/index.asp)
• Center for Disease Control
(http://www.cdc.gov/ViolencePrevention/youthviolence/schoolvio
lence/index.html)
• American Academy of Child and Adolescent Psychiatry
(www.aacap.org)
• Stop Bullying Now! (http://www.stopbullyingnow.hrsa.gov/kids/)
THANK YOU
QUESTIONS AND DISCUSSION