Sociopathic Behavior in Children

Transcription

1 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

2 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 Will be discussing off-label uses of medications

3 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

4 Violent Angry Sociopath Delinquent AggressionDefiant Oppositional Psychopath Callous-Unemotional Conduct Disorder

5 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

6 Key Statistics (National Center for Education Statistics) 55.7 million kids school K homicides and 5 suicides 1.5 million nonfatal crimes Total nonfatal acts

7 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at 3 years old only 28% display little or no aggression (Tremblay 2004) Naturally selected trait that may be somewhat outdated English philosophers considered the restraints of unsanctioned aggression to be the only justification to intrude on personal liberties

8 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

9 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

10 DSM-IV Diagnoses Oppositional Defiant Disorder (ODD) Negativistic, hostile, and defiant behavior including losing temper, refusing to comply, often angry, spiteful Diagnosis generally given to younger children 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 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

11 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

12 Reactive Aggression More impulsivity More anxiety/neuroticism Lower verbal intelligence Higher rates of dysfunctional parenting Higher threat appraisal

13 Think anxiety driving aggression when Aggression is more reactive Predictable in certain environments Rating scales show increase of both disruptive behavior and mood/anxiety Child Behavior Checklist

14 Three Dimensions of Psycopathy Callous-Unemotional traits Arrogant and deceitful personal style Impulsivity, irresponsibility and proneness to boredom

15 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

16 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

17 Inventory of Callous- Unemotional Traits

18 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%

19 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

20 Aggression Sex Differences Mother Report mean raw score age 3 age 5 age 7 age 10 age 12 boys girls Slide courtesy of J Hudziak, MD

21 Aggression Sex Differences Teacher Report mean raw score age 5 age 7 age 10 age 12 boys girls Slide courtesy of J Hudziak, MD

22 Demographic Variables Associated with 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 Aggression 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

23 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)

24 Parenting Aspects Coercive family processes Lack of supervision Lack of positive involvement Inconsistent discipline Outright abuse

25 Mean Aggressive Syndrome Averaged Across Cohorts Mean Raw Score /5 6/7 8/9 10/11 12/13 14/15 16/17 18 Age 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 Psychopathology, 9,

26 Mean Delinquent Syndrome Averaged Across Cohorts Mean Raw Score /5 6/7 8/9 10/11 12/13 14/15 16/17 18 Age 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 Psychopathology, 9,

27 Life Course of Aggression Aggression Age Childhood Limited Adolescent Limited Childhood Persistent Adolescent Persistent Adult Onset Note: Expansion of life-course-persistent versus adolescence-limited groups found by Moffitt (Psychol Review 1993)

28 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

29 Hypothalamic Attack Area Neuroanatomy of Aggression Cortex Executive Function Impulse Control Amygdala Threat processing and memory Brainstem Arousal to threat

30 Neuroimaging Studies in Psychopathy Less activation of frontotemporal lobes Smaller hippocampus (acquisition of fear learning)

31 Physiological Studies Autonomic hypoarousal and hyposensitivity especially when studying children with callousunemotional symptoms Not good evidence regarding abnormal male hormones

32 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

33 Genetics No aggression gene Multiple genes with each with smaller effects Many genes related to formation and metabolism of brain chemicals

34 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

35 Genes and Environments Study of Swedish Adoptees Risk Chance of Criminality No history in biological or 2.9% adoptive family Adoptive family only 6.7% Birth family only 12.1% Both birth and adoptive 40% From Victoroff, Human Aggression, 2009

36 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)

37 The Harry Potter effect!

38 The Harry Potter effect! -r

39 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

40 Treatment of Aggression Emotion Expression Intervention for the emotion Intervention for the expression

41 What Doesn t Work Boot camp coercive treatment not found to be effective and may make things worse

42 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

43 Parent Management Programs

44 Publications for Parents

45 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

46 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

47 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)

48 Treatment by Type Reactive Aggression: teaching skills (e.g. Collaborative Problem Solving), identifying triggers, reducing anxiety Proactive Aggression: Changing rewards structure, influences, and environment

49 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)

50 Resources Promising and Proven Programs on Youth Violence Prevention (Office of Justice National Youth Violence Prevention ( Center for Disease Control ( lence/index.html) American Academy of Child and Adolescent Psychiatry ( Stop Bullying Now! (

51 THANK YOU QUESTIONS AND DISCUSSION