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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?
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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
• Introverted­asachild;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
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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
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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!
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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
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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?
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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…
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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
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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…
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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
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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
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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/
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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?”
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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
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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…
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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.
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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
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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)
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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