1

frontpage

TheRootsofAntisocialBehaviorinYouth

MACMH2010

DavidX.SwensonPhDLP,TheCollegeofSt.Scholastica

Objectives

• Todescribetheantisocialcontinuumfromoppositionaldefiantdisordertopsychopathicpersonalitydisorder

• Todescribedevelopmental,neurological,andrelationalinfluencesintheformationofantisocialfeaturesinconductdisorders

• Todiscusskeyimplicationsforintervention&managementofantisocialbehaviorwithyouth

Noexcuses,justexplanations

Whatweknowabouttheantisocialcontinuum:Persistentandserious

• Persistentaggressionafterthirdgradeispredictiveofcontinuedaggressiveness;itsstabilityissimilartothatofintelligence;themoreseverethemorestable

• Conductproblemscanbepredictedwith80%accuracy5yearslaterbasedonsocialskills,negative/aggressivebehavior,anddisciplinarycontacts

• Adolescentswithpsychopathyatage13wereashighatage24(evenhigherwhenpoor,delinquentpeers,&abuse)

• Threeyearsafterleavingschool,70%ofantisocialyouthhavebeenarrestedatleastonce.

Whathappenstonicekids…

…Thatmakesthemgobad?

2

PsychopathyChecklist‐Revised–The“GoldStandard”

1. Glibness/superficialcharm(1)

2. Grandiosesenseofself‐worth(1)

3. Pathologicallying(1)

4. Cunning/manipulative(1)

5. Lackofremorseorguilt(1)

6. Shallowaffect(1)

7. Callous/lackofempathy(1)

8. Failuretoacceptresponsibilityforownactions(1)

9. Needforstimulation/pronenesstoboredom(2)

10. Parasiticlifestyle(2)

11. Poorbehavioralcontrols(2)

12. Earlybehaviorproblems(2)

13. Lackofrealistic,long‐termplans(2)

14. Impulsivity(2)

15. Irresponsibility(2)

16. Juveniledelinquency(2)

17. Revocationofconditionalrelease(2)

18. Promiscuoussexualbehavior(T)

19. Manyshort‐termrelationships(T)

20. Criminalversatility(Hare,1986)(T)

Factor1:Callousemotionalandinterpersonaldetachment;affectiveimpairment

Factor2(ASP):Chronicandsociallydeviantantisocialbehaviors&lifestyle

Harecharacteristics

?

Meetthepsychopath…

• Parentalalcoholabuse

• Paternalabandonment

• Exposuretofatherbeatingbrothertodeath

• Multipleheadinjuriesfromparentalabuse,fighting,recklessness

• Learningdisabilities

• Introverted&shyasachild;charmingasadult

• Peerteasing&rejection;relievedbybeatingthem

• Compulsivegambling

• Firstmurderage14;tortured&killedanimals,claimed200people

RichardKuklinsky(The“Iceman”)

"WhenI'mgood,I'mverygood.WhenI'mbad,I'mbetter."(MaeWest)

PotentialProgressioninPersonalityDisorder

PDDADHDFAS/FAEBipolarLDetc…

OppositionalDefiantDisorder

ConductDisorder

AntisocialPersonalityDisorder

PsychopathicPersonalityDisorder

InattentionPoorsocialskillsLearningdeficits

AggressionDestructionDeceitfulnessRuleviolation

HostileDefiantNegative

CriminalactsImpulsivenessDisregardsafetyIrresponsibilityLackremorse

StimulusseekingLackgoalsParasiticPredatoryViolent

80%ofkidswithADHDaschildrencarrieditintoadolescence,and60%ofthosehaddevelopedODDorCD.100%ofantisocialpersonalitydisorderhaveDxasCDasyouth.

6‐16%boys2‐9%girls

1%PDD1‐20%ADHD1%FAS/FAE4‐6%Bipolar2‐8%LD

16‐22%

3%males1%females

1%

40‐50%ofCDbecomesASP

3

Thehighcostofantisocialbehavior

• Highqualityearlychildhooddevelopmentprogramshavehighcost‐benefitratiosof$3forevery$1invested(Lynch,2004)

• Outofdistrictschoolplacementcancostabout$200,000/year

• Bythetimeyoutharefinallyreferredtodaytreatmentprogramstheyhavealreadycostabout$250,000inservices

• Earlyinventionprogramscanpreventasmanyas250crimesper$1millionspentwhilethesameamountspentinprisonswouldpreventonly60suchcrimesayear)

• Byage28,thecostsforpublicserviceforindividualswithconductdisorderwere10timeshigherthannon‐CDpersons,especiallyrelatedtocrime(Scott,etal.,2001)

• Antisocialpersonshavelongerandmoreperiodsofcostlyunemployment

• Thecostofincarcerationperprisonerperyearis$20,000‐$50,000;thedamagetopeopleandsocialinstitutionshasbeenestimatedatadditional$50,000annually

• Recurrent/lifetimeincarcerationcostsabout$3millionperpersonNOTcountingtheindirectcostsofadjudication,damagetovictims,andrelatedcosts

So,what’sthebigdealifsofewpeoplehaveit?

1. Losestemper2. Argueswithadults3. Activelydefiesor

refusestocomplywithadultsrequestsorrules

4. Deliberatelyannoyspeople

5. Blamesothersforhis/hersmistakes

6. Touchyoreasilyannoyed

7. Angryorresentful8. Spitefulorvindictive

1. Bullies,threatens,&intimidates2. Initiatesphysicalfights3. Usedweaponthatcancause

seriousphysicalharm4. Physicallycrueltopeople5. Physicallycrueltoanimals6. Stolenwhileconfrontingvictim7. Forcedsexualactivity8. Deliberatelyengagedinfire

settingwithintentionaldamage9. Deliberatelydestroyedproperty10. Brokenintosomeone’shouse,

building,car11. Liestoobtaingoodsorfavorsor

avoidobligations12. Stolennontrivialitemswithout

confrontingvictim13. Staysoutatnightdespite

parentalprohibitions14. Runawayfromhomeovernight

twicewhilelivinginparent/surrogatehome

15. Truantfromschool

1. Glibness/superficialcharm(1)2. Grandiosesenseofself‐worth(1)3. Failuretoacceptresponsibilityforown

actions(1)4. Pathologicallying(1)5. Cunning/manipulative(1)6. Lackofremorseorguilt(1)7. Shallowaffect(1)8. Callous/lackofempathy(1)9. Parasiticlifestyle(2)10. Poorbehavioralcontrols(2)11. Earlybehaviorproblems(2)12. Lackofrealistic,long‐termplans(2)13. Impulsivity(2)14. Irresponsibility(2)15. Needforstimulation/pronenessto

boredom(2)16. Juveniledelinquency(2)17. Revocationofconditionalrelease(2)18. Promiscuoussexualbehavior(T)19. Manyshort‐termrelationships(T)20. Criminalversatility(Hare,1986)(T)

OppositionalDefiance ConductDisorder Antisocial/Psychopathy

Amatterofseverity&quality

InventoryofCallous‐UnemotionalTraits

http://fs.uno.edu/pfrick/ICU/FactorAnalysis.pdf

Callous‐Unemotional ImpulsiveConduct(ADHD)

• Dysfunctionalfamilies

• Reactiver/tinstrumentalaggression

• Highemotionalreactivitytothreatorother’sdistress

• Lowheritability

• Responsetoangryfaces

• Noamygdaladysfunction

• Fearlessness&thrill‐seeking

• Stablebehavior

• Severe&persistentaggression

• Instrumentalaggression

• Highlyheritable

• Poorprocessingfear&distressinothers

• 2ormoreSxarerelatedtosignificantimpairment

• Lessresponsivetoparentingintervention

• LessresponsivetobehaviorTx

Dolan,M.(2008).NeurobiologicalDisturbancesinCallous‐UnemotionalYouths.AmericanJournalofPsychiatry,165,668‐670.

DifferencesbetweenCallous‐UnemotionalandImpulsiveYouth

4

Callous/Unemotionalyouthhavemorepolicecontacts

Borntobewild?

• In19721,7953year‐oldswereenrolledinalongitudinalstudyoftraitdevelopmentinpsychopathy.Toddlerswereratedfordisinhibitedtemperament,stimulationseekingandfearlessness.Physiologicalreactionsbyskinconductancestartleresponsewasalsomonitored.

• 25yearslater335adultswerereassessedusingaself‐reportversionofthePCL‐R

• Adultswithhigherpsychopathyscoreshadmarkeddifferencesas3year‐olds:lessfearful/inhibited,morestimulusseeking,andreducedsensitivitytonegativestimuli.

Glenn,A.L.,Raine,A.Venables,V.H.,&Mednick,S.(2009).Earlytemperamentalandpsychophysiologicalprecursorsofadultpsychopathicpersonality.PersonalityDisorders:Theory,Research,andTreatment,S(1),46‐60.

So,howdotheygetthatway?

• heritabilityofASP(aswellasprosocialbehavior)estimatedat50%

• traumamodifiestherisk

• incompetentparentingfurthermodifiestherisk

Naturenurture

24.5%of143 14.7%of204

20.0%of1226 13.5%of2492

Mednick,S.A.,Gabrielli,W.H.,&Hutchings.B.(1984),Geneticinfluencesincriminalconvictions:Evidencefromanadoptioncohort.Science,224,891‐894.

NatureorNuture?–yes,both!

5

FetalAlcoholExposure

• 1‐2casesper1000youthhaveFASD;forwomenwhoalreadyhaveonechildwithFAStheriskis771per1000

• PrenatalexposureresultsintwicetheriskfordevelopmentofAxis‐II(personality)disorders,includingantisocialpersonality(Barr,etal.,2006)

• TheWashingtonGroupfounda19%co‐morbiditybetweenFASDandASP(Famy,etal.,1998)

• FASDisrelatedtoadultantisocialbehaviorregardlessofpreviousconductdisorder(Langbehn&Cadoret,2001)

• FAS/FAEisrelatedtocognitivedefects,lowIQ,impulsivebehavior,reducedempathy,lying,cheating,stealing,attentiondeficit,moodinstability,(Streissguth,1991) Greatestfetalsensitivity

• MAOA‐LgeneontheX(male)chromosomeappearstoweakenbraincircuitsthatregulateimpulses,emotionalmemoryandthinking,andproducehyperactivealarmcenter

• Itbreaksdownkeymoodregulatingchemicalmessengers(espserotonin)

• Reducesvolumeofcingulategyruscortex(bluearea)thatregulatesimpulsiveaggression

• Thisgenecombinedwithchildhoodabuseincreasesriskofimpulsiveaggression

Violence‐relatedGene

CaspiA,McClayJ,MoffittTE,MillJ,MartinJ,CraigIW,TaylorA,PoultonR.Roleofgenotypeinthecycleofviolenceinmaltreatedchildren.Science.2002Aug2;297(5582):851‐4.

•discomfort•hot/cold•hungry•happy•afraid•angry•tired•wet

•eyecontact•cooing•crying•smiling•reaching•grasping•approaching•following

•prolongedgazing•kissing•cuddling•fondling•highvoicing•rocking•rhythmiccontact

AvailabilitySensitivityResponsivenessConsistency

Secureattachment•trust•safe/secure•regularity•easiertocomfort•moreaffectionate

NormativeHealthyAttachment

•seekcloseness&reciprocity•frustrationtolerant•highintimacy•longlastingrelationships•highlevelsofcommitment•highrelationshipsatisfaction•stressresilient•fewerphysical&psychologicalproblems•lessaggressive,morecooperative•highbelonging

Normalattachment

AttachmentProblems

UnresponsivetoComforting•severeillness•prematurebirth•surgeries/pain•hyperactive•hospitalizations•colicky•autistic•FAS/FAE

•mentalillness•postpartumdepression•attachmentdisordered•chemicalabuse•physicalillness•multiplecaretakers•frequentmoves•criminalbehavior•preoccupation•separation/divorce•death•PDD

InsecureAttachment•untrusting•fearful•angry

•physicalabuse•domesticviolence•absence•neglect•inconsistency•over/understimulate•over/underattentive•rejecting

Poorattachment

Parenttoblameforpsychopathy?

Mack,T.D.andHackney‐Hansen,A.,2008‐03‐05"PsychopathicTraitsandAttachmentBehavior:DoesaPredictableRelationshipExist?"PaperpresentedattheannualmeetingoftheAmericanPsychology‐LawSociety,HyattRegencyJacksonvilleRiverfront,Jacksonville,FL

6

Psychopathyandyoungoffenders:Ratesofchildhoodmaltreatment,CorrectionalServiceCanada.http://www.csc‐scc.gc.ca/text/pblct/forum/e07/e071f_e.shtml

Themoreabuse,themorebehaviorproblems…

Early/adolescentonset

• Neuro‐developmentalprocesses&impaIrments

• Greaterstability&severity

• Increasedfamilydysfunction,parentalseparation

• Minoraggressionescalatingwithage

• Criminalversatility

• Peerrejection/poorsocialskills

• Slowheartrates,poormemory,adaptability

Age8‐10 14 1850%43%

• Drivenbysocialprocesses

• Majority(76%)ofyouthconductproblems

• Exaggerationofnormaladolescentrebellion

• Maintainempathy&avoidpeerrejection

• Startwithseriousdelinquency

• Tendstoremitinadulthood

EarlyOnsetConductProblems AdolescentOnsetConductProblems

Whatwoulditbeliketolivehere?

Howwouldyouexplainthistofriends?

“uh,yeah…we’rekindalaidbackhereathome…”

MeetmyMom&Dad:ChangeswithMethaddiction—Whathappenstochildrenwhoseetheirparentundergoingthis?

7

Lesseasily‐socializedyouthrequiremorecompetentparentingtoavoidpersonalitydisorders

•Neglect•Conflict•Parentaldeviance•Familydisruption

TheappealofGangs

• asubstituteforfamilyclosenessandintimacy

• safetyandprotection

• listeningandacceptanceoftheperson

• acceptanceofdeviantbehavior

• reinforcementofdeviantbeliefs

• provideuniquenessandspecialstatus

• mutualstereotypingofothersoutsidethegroup

• strongcohesionandboundaries

• channelforunconventionalbehaviorandaggression

Gangsandcohesivejuvenilegroupsoftenprovidewhattheyouth’sfamilydoesnotprovide:

Gangs

Createsasenseofculture NormalTeenBehavior–Duh!

• Forgetful–leavesbehindandlosesthings,lateonassignments

• Impulsive,risktaking,reckless

• Poorjudgment,poordecisions,can’tforeseeconsequences

• Gangly,awkward,clumsy

• Misunderstanding,misreading,misinterpretations

• Stayuplate,can’tgetupearly

• Moody,overlysensitive,hysterics

• Shockingdress,tattoos,piercing

• Alcohol,druguse

• Argueswithlogicalandrationalreasoning

• Messyrooms,lockers,notebooks

Normalteen

“Typical”

Probablynot…

8

Risk

RiskTakingTeens:What(how)wereyouthinking!?

• About60%ofteensengageinpotentiallydangerousbehavior

• Thedropindopaminelevelsdecreasestheabilitytoexperiencepleasure

• Toobtainpleasure,morestimulationseekingoccurs:drugandalcoholabuse,extremesports,slashermovies,speeding,high‐risksex

• Teensshowlessbrainactivityinareasofthebrainthatmotivatethemtoreceiverewards(rightventralstriatum)

• Comparedwithadults,theyseekeasiermeanstogainrewards(e.g.,recklessness&drugs

• Theyhavedifficultymaintainingfocusonlongtermgoals

• Theytakehigherriskswithpeersthanwhenalone

Pruning

Pruning:UseitorLoseit!

• Synapseformationinthefrontalcortexareover‐produceduntiljustbeforepuberty(11girls,12boys),thenarepruned

• Excessconnectionsmeanstheyhavetroubletrackingmultiplethoughts&focusingattention

• Thegraymatteristhinnedat1‐2%peryear(upto50%!)asexcessconnectionsthatarenotusedareeliminated

• Abilitytolearnlanguagesdeclinesafterage12(changesinthecorpuscallosumfibers)

• Atthisage,teensbegindecidingwhattheywanttodoandhowtheywanttospendtime–ifitislayingaroundandwatchingTV,theotherpotentialsgetpruned.Whatyoudoiswhatyougetgoodat.

• PruningmayexposelatentproblemssuchasADHD,Tourette’s,andschizophrenia

Darkareasshowportionsofgraymatterprunedbetweenadolescence&adulthood

ComorbidityofDisordersinoffendingyouth(ODD&CD)

• 70‐87%ofjuvenileoffendershavepsychiatricproblems

• 50‐80%havelearningproblems,specialeducation,repeatgrade

• 45‐80%haveconductdisorder

• 55%havecharacterdisorder

• 65%withIQ<70engageininappropriatesexbehavior

• 35‐50%mooddisorder

• 30‐50%anxietydisorder

• 30‐40%attention/hyperactivitydisorder

• 20‐30%substanceabuse(6xalcohol,7xmarijuana)

comorbidity

9

ADHD

Impulsive:actbeforethinking

Makemistakes

Getintrouble

Discipline

Feelit’sunfair

Resentment

Defaulttodelinquent

peers

Actout

Hyperactivity

Outofseat,botherothers

Inattention,poor

concentration

Misreadsocialcues

Unpredictablerelating

Peeravoidancerejection

Poorworkingmemory,slowprocessing

Difficultylearning,get

behindRepeatedfailure

Embarrassment,frustration,

discouragementWithdrawal

Non‐attendance

Defiance

SampleADHDDynamics&Conduct

The Antisocial Brain:Emerging Research Evidence

Howthebrainworks…

10

http://www.acs.appstate.edu/dept/ps‐cj/neurology.htm

Poorcoordination,oddappearance,speech&visionproblems

Headaches,seizures,hypoglycemia,dizziness

NeurologicalDysfunctioninOffenders

26%Repeatoffendersbutonly5%of1sttimeoffendershadmaternaldrugabuse

83%offelonsreportthattheysufferedaheadinjurypriortotheirfirstencounterwithpolice;someaslateasage30(Sarapata,Herrmann,Johnson,andAycock,1998)

Stress

EffectsofStress&TraumaontheBrain

• Longtermexposuretostress&violenceproduceshighleveloffearhormone,cortisol(reducesconnections&mayshrinkhippocampus(memory)

• Childrenofneglectfulmothersaremoresociallywithdrawn,inattentive,cognitivelyunder‐achievinginelementaryyears

• Physical,verbal(repeatedyelling,scolding,criticism),sexualabuseisrelatedtodecreaseinworkingmemory

• Mayincrease“limbic(mood)irritability”producingabnormalEEGsassociatedwithaggression

• Repeatedrecollectionandobsessingcanintensifythestresseffects

• Stresstendstoshort‐circuitfrontallobeprocessing(whatlittlethereis)andswitchtoemotionalprocessing(resultinginover‐sensitivity)

• Childrenglobally(ratherthanchaotically)neglectedhaveenlargedventriclesorcorticalatrophy

Forebrain

• Planning• Attention• Judgment• Reflection• Prioritizing• Selfcontrol• Strategizing• Sequencing• Anticipation• Organization• Impulsecontrol• Secondthought• Workingmemory• Modulatingmood• Responseflexibility• Goal‐directedbehavior• Foreseeconsequences

BrainCEO:ForebrainorPrefrontalArea

…insteadtheyrelyontheiremotionalbrain

11

ThestrangecaseofPhineasGage

• Gagewasarailroadconstructionsupervisorin1848whena3½‐foot13lbtampingrodwasdriventhroughhisskullbyanexplosion.Thetampingrodseveredtheconnectionsinthelefthemisphere,frontalarea.Hewasknockeddownbutremainedconsciousandreturnedtoworkabout9monthslater

• PriortotheaccidentGagewasdescribedasmoral,hardworking,sensitive,conscientious,intelligent,capable,shrewdbutwelllikedbusinessman

• Followingtheaccident,hispersonalitychanged:hewasimpatient,capricious,lying,swearing,fighting,drinking,extravagant,seizureprone,andantisocial

Phineasgage

CorpusCallosum:Theconnection

• ConnectingLandRhemispheres,itisrelatedtocreativity,highertypesofthinking,intelligence,consciousness,andselfawareness

• Itchangesthroughoutchildhoodandtakesdifferentshapesfordifferentchildhoodillnesses;fullmaturityin20s

• Itsincreasingelaborationcanhelplearningfinally“click,”suchasinsight

• Abusedchildrenhavesmallercorpuscallosumandpoorerintegrationbetweenthehemispheres,andcanberelatedtopooremotionalregulation,cause‐effectthinking,recognitionofemotionsinothersorexpressionorownemotions,andconscience

• ASPshowed>whitemattervolume,>collosallength,<collosalthickness,&>connectivitybetweenhemispheres(Raine,etal.,2004).Largervolumeisrelatedto>affective&interpersonaldeficits,<autonomicstressreactivity.Thissuggestsarrestofearlyaxonalpruningorincreasedmyelination

Corpuscollosum

Stroopcolorwordtest

Undersocializedsubjectshavemoredifficultythancontrolsubjectsinnamingthecolor,suggestingfrontallobeinvolvement(Waid&Orne,1982)

The“Oops”Center–anteriorcingulategyrus

• Thecingulateisresponsibleforhelpingfocusattention

• Linkscingulateandemotionalhippocampusforintegratingreason&emotiontoguidedecisions

• Undergoeshighmyelination(doubles)duringadolescence

• “Oopscenter”anticipatesrisk,detectsandkeepsusfrommakingerrors

• Mayinvolveabilitytoempathize—maynotbeabletorecognizeandappreciateother’sfeelingsuntilmidtolateteens

Oopscenter

12

IowaGamblingTask:Don’ttheyknowthey’relosers?

Task:Chooseacardtowingamemoney.Decksvaryinpayoff:somepayconstantlowreward,whileotherspayhighbutalsohavelargepenalty.

• HealthySsstaywith“gooddecks”whileASPsstickwith“baddecks”evenwhentheyknowtheyarelosingoverall

• HealthySsshowGSRstressresponselongbeforetheyconsciouslyrecognizelosing;ASPsneverdevelopthisreactiontopendingpunishment

• Impairmentrelatedtoorbito‐frontaldysfunction(the“oops”spot)

• ASPshowshypersensitivitytorewardandhyposensitivitytopunishment

• Theymaynotbeabletolearnsocialconventionsassociatedwithlossandgain

Mirrorneurons:Monkeysee,monkeydo

• Newbornsasyoungas72hoursoldcanimitatesomefacialexpressions

• Amirrorneuronisaneuronwhichfiresbothwhenananimalperformsanactionandwhentheanimalobservesthesameactionperformedbyanother

• mirrorneuronshavebeenfoundinthepremotorcortex(motorbehavior)andtheinferiorparietalcortex(distinguishingself/other)

• Theseappeartobeinvolvedinunderstandingintentionsofothers,empathy,predictingactionsofothers,andsocialbonding

• Suchempathyusuallypreventsusfromcausingdiscomforttoothers(Blair’stheoryofViolenceInhibitionMechanism)

Poorrecognitionofemotionalcues(impairedempathy)

ConductDisorderedYouth:

• Whenreadingemotion,teensrelymoreontheamygdala(L),whileadultsrelymoreonthefrontalcortex(R).

• Errorsinevaluatingmotiveandintent(evennormalteensare2xthatofadults);Misinterpretsocialcues&attributehostileintentions

• Abnormalstandardsandexpectationsregardingownbehavior;Teaseothersbutrespondnegativelytoothers

• Impairmentindeepemotionalrelationships(thatcomefromreadingemotionalcues)

• Conclusion:theneuralpathwaysthataresupposedtoprocesshumanemotionareeithernon‐functionalorareprocesseddifferently–psychopathsdon’tidentifywiththeemotionalstressoftheirvictims

“Thatwasfunny!”:Bulliesenjoythepainofothers

• Aggressiveyouthwereshownclipsofapianisthavingfingerspinchedbyclosingthepianolidonthem

• Areasrelatedtoprocessingpainwereactivated,but…

• Soweretheamygdalaandvertralstriatum(rewardcenters)

• Unlikeunagggressiveyouth,aggressivesdidnotactivatemedialprefrontalortemperoparietaljunctionassociatedwithselfregulation(impulsecontrol)

• Youthwithoutaggressionproblemsdidnotshowthesameactivation,butinsteaditevokedempathy

http://huehueteotl.wordpress.com/category/science/neuroscience/

13

ThePost‐ItNotesofthebrain:WorkingMemory

• WMisthe“mentalworkspaceforstoring&manipulatinginformation–learningpotential

• Relatedtoliteracy&math(andacademicfailureinthese)

• Difficultyinproblemsolving

• Difficultyincause‐effectthinking,seeingpotentialconsequences

• “Goesinoneearandouttheother”

4x3+6–2=?Moral

Reasoning

ornot…

“Youarestandingnexttoaswitchinatrolleytrackandyounoticethatarunawaytrolleyisabouttohitagroupoffivepeoplewhoareunawareoftheirdanger.However,ifyouswitchthetrack,thetrolleywillhitonlyoneperson.Whatdoyoudo?”

TheBrainandEthicalReasoning:Thelesseroftwoevils

“Youarestandingonabridgeoveratrolleytrackbesideasingleperson.Againyounoticethattherunawaytrolleyisheadedtowardfiveunawarepeople.Doyoupushthesinglepersonontothetracktostopthetrolley?”

14

Braininjury&moralchoices:“Willingnesstoviolatemoralchoicesofanytype”

VentromedialCortex

Glenn,A.L.,Lyer,R.,Graham,J.,Koleva,S.,&Haidt,J.(2009).Arealltypesofmoralitycompromisedinpsychopathy?JournalofPersonalityDisorders,23(4),384‐398.

Koenigs,M.,Young,L.,Adolphs,R.,Tranel,D.,Cushman,F.,Hauser,M.,&Damasio,A.April19,2007).Damagetotheprefrontalcortexincreasesutilitarianmoraljudgments.Nature. Normalpeopleshowfear,startle,andavoidancereactionstopainfulstimuli–

psychopathsdon’t

Lykkenstudystartle

Theamygdalais17%smallerinpsychopaths

Non‐reactivitytoEmotionalStimulation

Antisocialsreacttohorrificpicturesthesameastheydotoneutralpictures

Developmentofbehaviordisordersinyouth

Pre‐family• poverty• single• unwanted• MI(depression)• AODA• teen/immature• abused• antisocial• divorce• assortativemating• transgenerationalproblems

Infancy•Prematurity•lowbirthweight•braininjury•attachment•hyperreactive•“colicky”•unhealthy•disability•pain•multipleplacements

Family•cohesion•flexibility•poorboundaries•inconsistentdiscipline•poorsupervision•maritalrelationship•handleemotions•poorrolemodeling•criminality•physical,emotional,sexualabuse•explicitsexuality•disorganization•cold,rejecting•largefamily•fatherabsence•longunemployment

Peers•delinquent/deviantpeers•antisocialsibs•bullying•rejectionbynormgroup•attention/recognition•belonging•actout•revenge

PROBABLEOFFENSE

Environmental•pop.density•poorhousing•mobileresidents•discrimination•mediaviolence•culturalnorms•nosupportsvc.•discrimination•crimerate

Legal/Offense• Hxofviolence• Type/frequency/severity• Non‐violentoffending• Earlyonsetofviolence• Pastsupervisionfailure• Domesticviolence• Escalatingpattern• Victimagevulnerability• Deviantarousal

Capacity• LowIQ• LD• ADHD• FAS/FAE• Bipolar• PDD• Braininjury

15

InternalControls

ViolenceTheVitalBalance

Personality‐‐Whatpreventsyoufromoffending?

•values(“It’swrong”)

•empathy(“itwouldhurtothers”)

•consequences(“I’dgetintrouble”)

•egodystonic(“that’snotme”)

•shame/embarrassment(“whatwouldothersthink”)

•esteem(I’dfeelawful”)

•identification(“wouldn’twantthattohappentome”)

•personalresponsibility(“Iwouldberesponsible”)

•selfmonitoring&control(“I’dstopmyself”)

•coping(“otherwaystodealwithtension”)

ExternalControls

Support• Nurturance• Feedback• Availability• Consistency• Positiveinvolvement

Sanctions• Intensivesupervision• Legalcharges• Elec.Monitoring• Placement

Theearlysolution…lobotomy!

•In196612year‐oldHowardDullybecametheyoungestrecipientoftheicepicktransorbitallobotomyfor:“beingunbelievablydefiant…objectsgoingtobed…daydreaming…andsays‘Idon’tknow.’”

•Lobotomydeveloper,Dr.WalterFreemantravelledtheUSinhisLobotomobileconductingupto2500ofthe10minuteproceduresin23statesfrom1936‐1967

MostofAmerica'spopulacethinkitimpropertospankchildren,soIhavetriedothermethodstocontrolmykidswhentheyhaveoneof"thosemoments."

OnethatIfoundeffectiveisformetojusttakethechildforacarrideandtalk.Theyusuallycalmdownandstopmisbehavingafterourcarridetogether.

I'veincludedaphotobelowofoneofmysessionswithmyson,incaseyouwouldliketousethetechnique.

Sincerely,AFriend

Letterfromaparent…

16

Traditionaltreatmentdifficultieswithantisocialadjustments

• Lowmotivationtochange(lowanxiety)

• Rarelyinitiatetreatment(CDTx)

• Noncompliancewithrequirements&rules

• Lowempathy,remorse,guilt

• Highlyimpulsive,risk‐taking&reckless

• Lackofinsightintoaffectivestate

• Avoidanceofpersonalresponsibility

• Noncompliantwithorabusemedication

• Lessreactivetoaversion&punishment

• Superficialrelationships;lacktherapeuticalliance

• Noncomplianceanddisruptionofothers’Tx

• Tendtofocusonprimarygoal&ignoreperipheral&cost/benefitreasoning

• Lackofunderstandingofantecedentsofbehaviormakerelapsepreventionstrategiesdifficult

• Cannottrustself‐report,deceptive,manipulative

“HowamIsupposedtoknowifI’minnocent…I’mapsychopath!”

Parentalcontributiontoempathy

EarlyInterventionwithfamilies:Parentalcontributiontoempathy

• Secureattachment&nurturing:responsivenesstoinfant,available,sensitivity,consistency

• Takechildrenseriously:respectfeelings,preferences,questions

• Practicecooperating:demonstratingcollaborationratherthancompetition

• Guiding&explaining:valuesharing,caring,helping,explainwhyprosocialbehaviorsareimportantandappreciated,howaggressiveandselfishbehaviorsharmsothers,interveningwhenchildisselfishorcruel,explainhowothersfeel

• Modeling:generosity,charitabletoothers,practicewhatpreached,smallactsofkindness

• Promotingandpraisingprosocialselfimage:encourageopportunitiestoexperiencecaring&helping,viewselfascaringandhelping,volunteering,internalratherthanexternallocusofcontrolforaltruism

Components of Empathy Enhancementfor Juvenile Offenders

• Ability to identify and express emotions

• Development of good listening skills in order to be ableto identify feelings of others

• Address lack of awareness of the devastating short and long termemotional impact that the behavior had on the victim(s); Constructing aseries of apologies to his victims

• Identification of feelings prior to, during and after offenses; address lack ofremorse

• Comprehension of how anger, stress and values influence their reactionsto others

• Modification of behavior out of concern for others’ feelings

• Dealing with own victimization

• Reinforcement of prosocial behaviors (4:1 ratio)Questionableifclientisolderteen,repeatoffender,psychopathic&sadisticindicators,poorresponsetotreatment

Theyellowareaofthebrainistherightlateralorbitofrontalcortex,orrightltOFC,whichhasbeenpreviouslyassociatedwithdecreasedcontroloveravarietyofbehaviors,includingreactiveaggression.Thegraphillustratesthatasthenumberofviolentmovieswatchedincreased(stimulusnumberalongbottomofgraph),therightltOFCactivitydiminished.

Eliminateviolentmovies&videos:Repeatedviewingofviolentprogramsreducesactivityofviolencecontrolareas:

•rightlateralorbitofrontalcortex(impulsecontrol)

•Amygdala(fear,anger)

•Afterviewingviolencetheareasassociatedwithplanningaggressiveactionbecamemoreactive

•ThesechangesdidnotoccurwhenSsviewedmovieswithnon‐violentscenesbuthadhorrororphysicalactivity

ColumbiaUniversityMedicalCenter(2007,December10).ThisIsYourBrainOnViolentMedia.ScienceDaily.

17

Teachingimpulsecontrol

• “Stop!Think!Act!:useateveryopportunity,graphicposters,strongverbalpraise

• Slowdown:timeout,counttoten,3deepbreaths,“warmer—colder”,musclerelaxation

• Problemsolvingpuzzles,mazes,manipulativepuzzles(e.g.,“tavernpuzzles,TowerofLondon)

• Leadthechildthroughtheproblemsolvingprocess(don’tjustdirectortell)

• Teachawareness:“Insteadof“leavemealone&sitdown”try“whatdoyouseemedoingnow?Doyouthinkthisisagoodorbadtimetoaskmeaquestion?Whatshouldyoubedoing?

• Behaviorshaping:givingsmall,tangiblerewardsforcooperationwithexternalcontrolofimpulsivity.“YoucanoneM&MnoworfiveifyouwaittilIfinish.”

• Modelimpulsecontrolandshowhowtodiscussthoughtsandfeelings

“OuttatheBlue!”:Deconstructingactions

1. Whathappenedin(focusonthesuddenness)

2. Elaborateonthedetailandstartmapping

3. ColumboMode:“Whathappenedjustasecondbeforethat?”

4. …andjustbeforethat?(focusondetailsofthoughts,feelings,andbehaviors)

5. Askifthemapaccuratelydescribesthesequence

6. Whatmighthappenifitwerestoppedateachcriticalstep?

7. Practicere‐enactment.Starttoescalate,thenstopandexamine(practiceinterruption)

SampleFamilySystemDynamics:It’salltiedtogether–treatthesystem!

Father’sStrict

Mother’sleniency

Parentalconflict

Verbalabuse

Physicalabuse

WithdrawalbyeachSelf‐

justification

Sonobserves

Angryaboutabuse

Depressed,preoccupied

aboutsituation

Poorconcentration

atschool

Pooracademicperformance

Frustrationwithschool

Truancy

Referredfordiscipline

Hypersensitive,reactive

DefiantwithteacherFightingwith

peers

Son’sbehaviorissues

CoordinateInterventions—Whatparents&fosterparentsshould

sharewiththerapists

• changeinbehavior(improvementsanddeterioration)

• whatworks&whatdoesn’t

• followthroughwithbehaviorassignments

• issuesathomethatshouldbediscussedintreatment

• performanceandbehavioratschool

• responsetocontactswithbiologicalparents

• evidenceofwarningsignsofpendingseriousbehavior

• responsetodisciplineandaffection

• compliancewithmedication&treatment

• responsetomedication

Whattherapistsneedtoknow

18

JuvenileSexOffenders Medicationforantisocialbehaviors

• Antidepressants

• SSRI(Prozac,Zoloft,etc.):reducedepression,anxiety,OCD,moodswings

• Tricyclics(e.g.,Elavil,Tofranil):psychoticdepression&ADHD

• MAOI(e.g.,Marplan,Nardil):angercontrol,impulsivity,interpersonalsensitivity,socialanxiety

• Lithium:reduceimpulsive,anger,combativeness,explosive,&emotionallyunstablebehavior(esp.bipolarmoodswings)

• Benzodiazepines(e.g.,Xanax,Klonopin,Valium):controlanxiety&insomnia,episodicaggression(potentiallyaddictive)

• Psychostimulants(e.g.,amphetamine,methylphenidate):ADHD

• Anticonvulsants(e.g.,Carbamazapine):episodic(limbic)dyscontrolincludingangryoutbursts,violence,&self‐mutilation

• Alcoholtreatment:Antabuse,Naltrexone,Campral,Topamax

Medicationrisksinclude:

• Timetoreachtherapeuticlevels

• Interactioneffectswithillicitdrugs

• Sideeffects&toxicity

• DietaryrestrictionwithMAOI

• Hoardingdrugsforoverdose

• Substanceabuseorrelapse

• Sellingmedications

• Defiance&noncompliance

• Mayrequireclosemedicalsupervision

• Onlyforsymptomatictreatment

Effectivenessofcorrectivethinking

EffectivenessofCorrectiveThinking

Highriskclients

• 66%reductionincrimeforthosewhocompletedtheprogram.

• 33%reductionincrimeforthosewhoenteredbutdidnotcomplete.

• 48%ofallclientspursuednonewcrime.

• 29.4%exhibitedadecreaseincrime.

• 6.4%showednochange.

• 15.6%exhibitedanincreaseincrime.

Averagenumberofcriminalcharges:

• Reducedbyslightlyover50%forallclientswhoenteredtheprogram.

• Reducedapproximately66%forthosewhocompletedtheprogram.

• Reducedbyapproximately33%amongclientsterminatedbeforecompletion.

• Reduced79.17%forthosewhocompletedandhadnopreviousarrests.

• Reduced36.36%forthosewhoterminatedpriortocompletionwithnopriorarrests.

Truthought'sCorrectiveThinkingTreatmentModelincludesfourstudiesdonebyUniversityofWisconsin,USDepartmentofJusticeNationalInstituteonCorrections,USDepartmentofJusticeBureauofJusticeAssistance(1988‐1993)

19

Individual counseling,interpersonal skills, behavioralcontracting

Interpersonal skills, teachingfamily home

Multiple services, restitution,probation & parole

Cognitive behavioral treatment,community residential programs,multiple services

Employment related programs,academic programs, advocacy,family & group counseling

Individual counseling, guidedand group counseling

Reduced caseload, probation &parole

Employment related programs,drug abstinence, wildernessprograms

Wilderness challenge, earlyrelease, deterrence andvocational programs

Milieu therapy

NoninstitutionalizedOffenders

InstitutionalizedOffenders

Positiveeffects,consistentevidence

Lessconsistentpositiveeffects

Inconsistentbutgenerallypositive

Inconsistentweakornoeffects

Consistentlyweakornoeffects

EffectivenessofinterventionsforSerious&ViolentOffenders

http://www.surgeongeneral.gov/library/youthviolence/chapter5/sec5.html

KeyPointsinTreatment

• Earlyintervention(childhood)ismoreeffectivethanlater(adolescenceandadulthood)

• Multimodalapproachesaremoreeffectivethansingularapproaches

• Minimizemanipulationbyhavingfrequentcollaborationamongparents&providers

• Decreasingfamilypathology&increasingcompetentparentingisessentialforyouth

• Empathytrainingworkswithyoungerclientsandthosewhoaremoresocialized;lesswellwithcallous&remorselessclients(mayactuallyincreaserecidivism)

• Holdclientstobehaviorchange,notjustattendancetoandcompletionofaprogram

• ODD,CD,andASPrespondtotreatment,butnoeffectivetreatmenthasemergedyetforthepsychopath

20