Sociopathic Behavior in Children

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 Expenses related to this talk or meeting NONE

Funding from NIMH (K08 MH069562) and the University of Vermont College of Medicine

Physician Scientist Award

Objectives

• Review concepts and definition of aggression and sociopathy as they relate to children

• Discuss new basic neurobiology and features of

childhood sociopathy

Soc

iopa

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Delinquent

Violen

t

Oppositiona

l

Ag

gre

ssi

on

Defian

t

Conduct Disorder

Ps

ych

op

ath

Angry

Callous-Unemotional

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

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

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• Naturally selected trait that may be somewhat outdated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

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,

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,

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

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

Think anxiety driving aggression when…

Three Dimensions of Psycopathy

•

Callous-Unemotional traits

•

Arrogant and deceitful personal

style

•

Impulsivity, irresponsibility and

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

Callous-

Unemotional

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%

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

0 2 4 6 8 10 12 14 me an r aw s co re

age 3 age 5 age 7 age 10 age 12 boys girls

Aggression Sex Differences – Mother Report

0 1 2 3 4 5 6 7 me an r aw s co re

age 5 age 7 age 10 age 12

boys girls

Aggression Sex Differences – Teacher Report

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

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

Mean Aggressive Syndrome Averaged Across Cohorts

0 2 4 6 8 10 4/5 6/7 8/9 10/11 12/13 14/15 16/17 18 Age Me a n R a w Sc o re Males Females

Figure appears in Stanger, C., Achenbach, T.M., & Verhulst, F.C. (1997). Accelerated longitudinal comparisons of aggressive versus delinquent behavior syndromes. Development and

Mean Delinquent Syndrome Averaged Across Cohorts

0 0.5 1 1.5 2 4/5 6/7 8/9 10/11 12/13 14/15 16/17 18 Age M ean Raw S c o re Males Females

Figure appears in Stanger, C., Achenbach, T.M., & Verhulst, F.C. (1997). Accelerated longitudinal comparisons of aggressive versus delinquent behavior syndromes. Development and

Life Course of Aggression

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

Brainstem

Arousal to threat Hypothalamic Attack Area

Amygdala

Threat processing and memory

Impulse Control

Cortex

Neuroimaging Studies in Psychopathy

•

Less activation of frontotemporal lobes

•

Smaller hippocampus (acquisition of

Physiological Studies

• Autonomic hypoarousal and hyposensitivity

especially when studying children with callous- unemotional symptoms

• Not good evidence regarding abnormal male

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

Genetics Shared E Unshared E

Hudziak, van Beijsterveld, Bartels, Rietveld, Rettew, Derks, Boomsma, Twin Research, 2003

Additive Genetics 60% Shared Envir 20% Unshared Envir 20%

Genes and Environments

Study of Swedish Adoptees

Risk Chance of Criminality No history in biological or

adoptive family

2.9% Adoptive family only 6.7% Birth family only 12.1% Both birth and adoptive 40%

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

The Harry Potter effect!

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

Treatment of Aggression

Emotion 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

“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)

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

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)

THANK YOU