Understanding the Antisocial Continuum: Implications for intervention & management David X. Swenson PhD LP Superior Conference WITC March 3, 2009

• To describe the antisocial continuum from children to adults • To describe brain and developmental influences in the formation of antisocial behavior • To identify and discuss key implications for intervention & management of antisocial behavior
No excuses, just explanations

What we know about the antisocial continuum
• Persistent aggression after third grade is predictive of continued aggressiveness; its stability is similar to that of intelligence; the more severe the more stable • Conduct problems can be predicted with 80% accuracy 5 years later based on social skills, negative/aggressive behavior, and disciplinary contacts • Adolescents with psychopathy at age 13 were as high at age 24 (even higher when poor, delinquent peers, & abuse) • Three years after leaving school, 70% of antisocial youth have been arrested at least once.
• 22% ODD, 6-16% CD, 3.6 ASP, 1% PPD in the US • 80% of incarcerated males and 65% of females have ASP; 20% are psychopaths • 75% abuse alcohol and 50% other substances • Psychopaths have 3-5x higher recidivism rate than antisocials (underestimate) • Psychopaths are responsible for more than 50 percent of serious crime

So, what’s the big deal if so few people have it?
The high cost of antisocial behavior
• High quality early childhood development programs have high cost-benefit ratios of $3 for every $1 invested (Lynch, 2004) • Out of district school placement can cost about $200,000/year • By the time youth are finally referred to day treatment programs they have already cost about $250,000 in services • Early invention programs can prevent as many as 250 crimes per $1 million spent while the same amount spent in prisons would prevent only 60 such crimes a year) • By age 28, the costs for public service for individuals with conduct disorder were 10 times higher than non-CD persons, especially related to crime (Scott, et al., 2001) • Antisocial persons have longer and more periods of costly unemployment • The cost of incarceration per prisoner per year is $20,000-$50,000; the damage to people and social institutions has been estimated at $50,000 annually • Recurrent/lifetime incarceration costs about $3 million per person NOT counting the indirect costs of adjudication, damage to victims, and related costs • Execution is more expensive than lifetime incarceration: Execution can be from $2.1 (CA) to 3.2 million (FL), and incarceration from $600K (FL) to $1.4 million (CA

What happens to nice kids… …That makes them go bad?

Hard core: The psychopathic personality (PCL-R) 1.
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Glibness/superficial charm (1) Grandiose sense of self-worth (1) Pathological lying (1) Cunning/manipulative (1) Lack of remorse or guilt (1) Shallow affect (1) Callous/lack of empathy (1) Failure to accept responsibility for own actions (1) Need for stimulation/proneness to boredom (2) Parasitic lifestyle (2) Poor behavioral controls (2) Early behavior problems (2) Lack of realistic, long-term plans (2) Impulsivity (2) Irresponsibility (2) Juvenile delinquency (2) Revocation of conditional release (2) Promiscuous sexual behavior (T) Many short-term relationships (T) Criminal versatility (Hare, 1986) (T)
Factor 1: Callous emotional and interpersonal detachment; affective impairment Factor 2: Chronic and socially deviant antisocial behaviors & lifestyle

• Parental alcohol abuse • Paternal abandonment • Exposure to father beating brother to death • Multiple head injuries from parental abuse, fighting, recklessness • Learning disabilities • Introverted & shy as a child; charming as adult • Peer teasing & rejection; relieved by beating them • First murder age 14; tortured & killed animals, claimed 200 people • Compulsive gambling
Richard Kuklinsky (The “Iceman”)

Risk assessment methods

How good a judge of lying are you?
• Specially trained FBI, CIA, military agents – 56-73% • Psychologists regarding safety –58-68% • Judges– 56-62% • Officers– 56% • General public– 50%
Most people are not that much better than chance!

Clinical judgment .67
ER dx of heart attack .94
PCL:SV .68
HCR-20 .76-.80
Multiple ICT Model .88
WA CTS Study .78
Brøset VCL .82
Computer enhanced .91
Prostate CA Age + PSA .74
+ Gleason + MRI .86
Rain forecasts .82
Severe storms .74

Hard core: The psychopathic personality (PCL-R) 1.
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Glibness/superficial charm (1) Grandiose sense of self-worth (1) Pathological lying (1) Cunning/manipulative (1) Lack of remorse or guilt (1) Shallow affect (1) Callous/lack of empathy (1) Failure to accept responsibility for own actions (1) Need for stimulation/proneness to boredom (2) Parasitic lifestyle (2) Poor behavioral controls (2) Early behavior problems (2) Lack of realistic, long-term plans (2) Impulsivity (2) Irresponsibility (2) Juvenile delinquency (2) Revocation of conditional release (2) Promiscuous sexual behavior (T) Many short-term relationships (T) Criminal versatility (Hare, 1986) (T)
Factor 1: Callous emotional and interpersonal detachment; affective impairment Factor 2: Chronic and socially deviant antisocial behaviors & lifestyle

The structure of psychopathy: PCL-YV Factor 1 Factor 2

All offenders (100%) APD (50%+) PCL-R Psychopaths (10-20%) White Collar “Successful Psychopaths” Many treatable with current programs Difficult to treat with current programs

“Successful” or White Collar Psychopathy?
• Andrew Fastow of Enron takes $30 million in kickbacks & cost shareholder >$70 million • Bernie Ebbers of WorldCom arranged for his telecom company to lend him $408 million as it went toward bankruptcy • John Rigas, founder of Adelphia cable TV, built a $13 million golf course for himself while shareholders lost $60 billion in investments • Brighter, ability to plan, self aware, but glib lying and manipulation with low empathy

McGregor, nd)

ASP Criminal behavior tends to fall off with age

Aging and violence
• Generally less violence, possibly due to lower testosterone or becoming more risk averse • Laub & Sampson (2003) followed 475 men from age 32-70 (selected based on adolescent reform school) • Violent crime peaked at an age later than property crime, but was half by age 40 and near zero by age 60 • 3.2% of “late peak” violent offenders showed reduced violence by half by age 50 and near zero by age 70 • Highest risk offenders (e.g., psychopaths, pedophiles; Hare PCL-R) do not show a decline with age (Hare, Forth, & Strachan, 1992)

Key Points in Defining ASP
• The condition occurs across all cultures and societies • There is consensus on the key features of the disorder • The behavior develops over a long period and is an expression of personality, not just an illness or reaction • Psychopaths can be loners and losers as well as successful but manipulative & callous people • ASP tends to peak during adolescence and decline about mid 30s, BUT psychopathy persists across age • Individual judgement is not a good predictor of lying or dangerousness • Assessment methods are fairly accurate in identifying level of severity and risk on the antisocial continuum

So, how do they get that way…?

Normative Healthy Attachment
• discomfort • hot/cold • hungry • happy • afraid • angry • tired • wet • eye contact • cooing • crying • smiling • reaching • grasping • approaching • following
Availability Sensitivity Responsiveness Consistency
• seek closeness & reciprocity • frustration tolerant • high intimacy • long lasting relationships • high levels of commitment • high relationship satisfaction • stress resilient • fewer physical & psychological problems • less aggressive, more cooperative • high belonging • prolonged gazing • kissing • cuddling • fondling • high voicing • rocking • rhythmic contact
Secure attachment
• trust • safe/secure • regularity • easier to comfort • more affectionate

Attachment Problems Unresponsive to Comforting
• severe illness • premature birth • surgeries/pain • hyperactive • hospitalizations • colicky • autistic • FAS/FAE
Insecure Attachment
• untrusting • fearful • angry • mental illness • postpartum depression • attachment disordered • chemical abuse • physical illness • multiple caretakers • frequent moves • criminal behavior • preoccupation • separation/divorce • death • PDD • physical abuse • domestic violence • absence • neglect • inconsistency • over/under stimulate • over/under attentive • rejecting

What would it be like to live here?
How would you explain this to friends?

Meet my Mom & Dad: Changes with Meth addiction — What happens to children who see their parent undergoing this ?

• Insecure attachment– unstable image of caregiver • Confusion over different caregiver & household rules • Poor, variable boundaries • Conflicted guilt over attachment to foster parents vs. parents • Mistrust, caution (due to previous abuse) • Displace anger onto new caregivers from past resentments • Learn superficial charm to manipulate others • Play people off against each other • Continuous testing to see if they are rejected • Fear of removal, loss, grief; closeness means pain • Preoccupation with fantasy of returning to family of origin

Less easily-socialized youth require more competent parenting to avoid personality disorders
• Neglect • Conflict • Parental deviance • Family disruption

The more abuse, the more behavior problems…
Psychopathy and young offenders: Rates of childhood maltreatment, Correctional Service Canada. http://www.csc-scc.gc.ca/text/pblct/forum/e07/e071f_e.shtml

Early Onset Conduct Problems
• Neuro-developmental processes & impaIrments • Greater stability & severity • Increased family dysfunction, parental separation • Minor aggression escalating with age • Criminal versatility • Peer rejection/ poor social skills • Slow heart rates, poor memory, adaptability
Adolescent Onset Conduct Problems
• Driven by social processes • Majority (76%) of youth conduct problems • Exaggeration of normal adolescent rebellion • Maintain empathy & avoid peer rejection • Start with serious delinquency • Tends to remit in adulthood Age 8-10  14  18
50% 43%

Summary of the two factors of the Psychopathy Screening Device in clinic-referred children
(Frick, et al., 1994)

Callous/Unemotional youth have more police contacts

Kids with callous-unemotional traits
• Less responsive to discipline/punishment (e.g., time-outs); “We’ve tried everything,” “I don’t care…” • Lack empathy & guilt • Deliberate or predatory aggression, deliberate rule breaking, stealing, lying & disobedience • Low level of emotionality and unresponsive to emotions in others; Fearlessness & thrill-seeking • Amygdala (fear, anger) & ventromedial prefrontal cortical dysfunction (recklessness) • BUT, they respond to incentives & rewards– ratio of rewards to punishment should be 4:1
Note: Kids with ADHD/impulsiveness problems & are not callous more often have family dynamics issues, have reactive rather than instrumental aggression, and have high levels of response to emotionality or threat

"When I'm good, I'm very good. When I'm bad, I'm better." (Mae West)

Comorbidity of Disorders in juvenile offenders
• 70-87% have psychiatric problems • 50-80% have learning problems, special education, repeat grade • 45-80% have conduct disorder • 55% have character disorder • 65% with IQ <70 engage in inappropriate sex behavior • 35-50% mood disorder • 30-50% anxiety disorder •
The Point: There are usually multiple problems, influences, and modifiers that must be considered & treated
• 20-40% attention/hyperactivity disorder • 20-30% substance abuse

60 factor analytic studies of 28,401 youth
Destructive A Property Violations Animal Cruelty B Aggression Assault Stealing Fire setting Covert Vandalism Lying Runaway Truancy Substance use C Status Violations Swearing Rule Breaking Spiteful Cruel Blaming Fighting Bullying Annoying Temper Defiance Arguing Angry Stubborn Touchy D Oppositional Nondestructive Overt
(Frick, et al., 1993)
ODD

The appeal of Gangs Gangs and cohesive juvenile groups often provide what the youth’s family does not provide:
• a substitute for family closeness and intimacy • safety and protection • listening and acceptance of the person • acceptance of deviant behavior • reinforcement of deviant beliefs • provide uniqueness and special status • mutual stereotyping of others outside the group • strong cohesion and boundaries • channel for unconventional behavior and aggression

Oppositional Defiance
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Loses temper Argues with adults Actively defies or refuses to comply with adults requests or rules Deliberately annoys people Blames others for his/hers mistakes Touchy or easily annoyed Angry or resentful Spiteful or vindictive
Conduct Disorder
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Bullies, threatens, & intimidates Initiates physical fights Used weapon that can cause serious physical harm 4.
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Physically cruel to people Physically cruel to animals Stolen while confronting victim Forced sexual activity Deliberately engaged in fire setting with intentional damage Deliberately destroyed property Broken into someone’s house, building, car 11. Lies to obtain goods or favors or avoid obligations 12. Stolen nontrivial items without confronting victim 13. Stays out at night despite parental prohibitions 14. Run away from home overnight twice while living in parent/surrogate home 15. Truant from school 4.
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Glibness/superficial charm (1) Grandiose sense of self-worth (1) Failure to accept responsibility for own actions (1) Pathological lying (1) Cunning/manipulative (1) Lack of remorse or guilt (1) Shallow affect (1) Callous/lack of empathy (1) Parasitic lifestyle (2) Poor behavioral controls (2) Early behavior problems (2) Lack of realistic, long-term plans (2) Impulsivity (2) Irresponsibility (2) Need for stimulation/proneness to boredom (2) Juvenile delinquency (2) Revocation of conditional release (2) Promiscuous sexual behavior (T) Many short-term relationships (T) Criminal versatility (Hare, 1986) (T)

1% PDD 1-20% ADHD 1% FAS/FAE 4-6% Bipolar 2-8% LD Potential Progression in Personality Disorder PDD ADHD FAS/FAE Bipolar LD etc… 16-22% Oppositional Defiant Disorder 40-50% of CD becomes ASP 6-16% boys 2-9% girls 3% males 1% females Conduct Disorder Antisocial Personality Disorder 1% Psychopathic Personality Disorder Inattention Poor social skills Learning deficits Hostile Defiant Negative Aggression Destruction Deceitfulness Rule violation Criminal acts Impulsiveness Disregard safety Irresponsibility Lack remorse Stimulus seeking Lack goals Parasitic Predatory Violent 80% of kids with ADHD as children carried it into adolescence, and 60% of those had developed ODD or CD. 100% of antisocial personality disorder have Dx as CD as youth.

Environmental
• pop. density • poor housing • mobile residents • discrimination • media violence • cultural norms • no support svc. • discrimination • crime rate
Pre-family
• poverty • single • unwanted • MI (depression) • AODA • teen/immature • abused • antisocial • divorce • assortative mating • transgenerational
problems Infancy
• Prematurity • low birth weight • brain injury • attachment • hyperreactive • “colicky” • unhealthy • disability • pain • multiple placements
Capacity
• Low IQ • LD • ADHD • FAS/FAE • Bipolar • PDD • Brain injury
Peers
• delinquent/deviant peers • antisocial sibs • bullying • rejection by norm group • attention/recognition • belonging • act out • revenge
PROBABLE OFFENSE Family
• cohesion • flexibility • poor boundaries • inconsistent discipline • poor supervision • marital relationship • handle emotions • poor role modeling • criminality • physical, emotional,
sexual abuse
• explicit sexuality • disorganization • cold, rejecting • large family • father absence • long unemployment
Legal/Offense
• Hx of violence • Type/frequency/severity • Non-violent offending • Early onset of violence • Past supervision failure • Domestic violence • Escalating pattern • Victim age vulnerability • Deviant arousal

Internal Controls External Controls Personality What prevents
you
from offending?
• values (“It’s wrong”) • empathy (“it would hurt others”) • consequences (“I’d get in trouble”) • ego dystonic (“that’s not me”) • shame/embarrassment (“what would others think”) • esteem (I’d feel awful”) • identification (“wouldn’t want that to happen to me”) • personal responsibility (“I would be responsible”) • self monitoring & control (“I’d stop myself”) • coping (“other ways to deal with tension”)
Support
• Nurturance • Feedback • Availability • Consistency • Positive involvement
Sanctions
• Intensive supervision • Legal charges • Elec. Monitoring • Placement

Key Points in Child Development
• Inheritance provides the potential, but experience shapes antisocial expression • Early onset of conduct problems is worse than adolescent onset • Parental and family dynamics are an essential part of treating youth • Antisocial behavior is essentially a failure in socialization, empathy, and values • Antisocial development occurs throughout early and teen development and provides many intervention points • Aggressive and antisocial behavior tends to be stable over the years without intervention • The ratio of risk to protective factors strongly influences antisocial development • There are different pathways to conduct disorders in youth

How the brain works…

Normal Teen Behavior – Duh!
• • • • • • • • • • • Forgetful – leaves behind and loses things, late on assignments Impulsive, risk taking, reckless Poor judgment, poor decisions, can’t foresee consequences Gangly, awkward, clumsy Misunderstanding, misreading, misinterpretations Stay up late, can’t get up early Moody, overly sensitive, hysterics Shocking dress, tattoos, piercing Alcohol, drug use Argues with logical and rational reasoning Messy rooms, lockers, notebooks

Functional Magnetic Resonance Imagery (FMRI)

How neurons communication with each other

• • • • • Myelination may not finish until early 20s It provides greater speed and efficiency It occurs earlier in girls than boys – show more emotional regulation Faster transmissions may overwhelm defective circuits in some conditions (e.g., schizophrenia) Development occurs from back to front

Poor coordination, odd appearance, speech & vision problems 70 Neurological Dysfunction in Offenders Headaches, seizures, hypoglycemia, dizziness 26% Repeat offenders but only 5% of 1 st time offenders had maternal drug abuse 60 50 40 30 20 10 0 Physical Head injuries Health Family Abuse Family AODA Repeat violent offenders Repeat nonviolent offenders Ist time Offenders 83% of felons report that they suffered a head injury prior to their first encounter with police; some as late as age 30 (Sarapata, Herrmann, Johnson, and Aycock ,1998) http://www.acs.appstate.edu/dept/ps-cj/neurology.htm

24.5% of 143 20.0% of 1226 14.7% of 204 13.5% of 2492
• heritability of ASP (as well as prosocial behavior) estimated at 50% • trauma modifies the risk • incompetent parenting further modifies the risk Mednick, S. A., Gabrielli, W. H., & Hutchings. B. (1984), Genetic influences in criminal convictions: Evidence from an adoption cohort. Science, 224, 891-894.

Born to be wild?
• In 1972 1,795 3 year-olds were enrolled in a longitudinal study of trait development in psychopathy. The toddlers were rated for disinhibited temperament, stimulation seeking and fearlessness. Physiological reactions by skin conductance startle response was also monitored.
• 25 years later 335 adults were reassessed using a self-report version of the PCL-R • Adults with higher psychopathy scores had marked differences as 3 year-olds: less fearful/inhibited, more stimulus seeking, and reduced sensitivity top negative stimuli.
Glenn, A. L. et al (2007) Early Temperamental and Psychophysiological Precursors of Adult Psychopathic Personality. Journal of Abnormal Psychology. 116.

MAO-A Gene & Abuse effects on antisocial behavior
• The MAO-A gene on the X (male) chromosome makes an enzyme that metabolizes serotonin, dopamine, & norepinephrine; low MAO-A means low neurotransmitters • Gene alone does not produce impairment, but combined with childhood abuse, the interaction predicts antisocial behavior • Reduces volume of cingulate gyrus cortex (blue area) that regulates impulsive aggression • It’s not the low MAO-A that causes it, it’s the absence of high MAO-A that protects against it
Caspi A, McClay J, Moffitt TE, Mill J, Martin J, Craig IW, Taylor A, Poulton R.
violence in maltreated children. Science. 2002 Aug 2;297(5582):851-4.
Role of genotype in the cycle of

Neglect & nutritional factors in early neurological development Decreased brain iron Iron deficiency anemia Poor feeding practices Disadvantaged environment Hypomyelination Impaired Dopamine function Delayed Neuro maturation Stress vulnerability Parenting Behavior pattern Learning experiences Functional isolation Poorer outcome Willis (2004) http://www.icctc.org/IHS-BIA%20CPT%20Handbook/neglect2004.pdf
Limited support for child dev.

Fetal Alcohol Exposure
• 1-2 cases per 1000 youth have FASD; for women who already have one child with FAS the risk is 771 per 1000 • Prenatal exposure results in twice the risk for development of Axis-II (personality) disorders, including antisocial personality (Barr, et al., 2006) • The Washington Group found a 19% co-morbidity between FASD and ASP (Famy, et al., 1998) • FASD is related to adult antisocial behavior regardless of previous conduct disorder (Langbehn &Cadoret, 2001) • FAS/FAE is related to cognitive defects, low IQ, impulsive behavior, reduced empathy, lying, cheating, stealing, attention deficit, mood instability, (Streissguth, 1991)

Effects of Stress & Trauma on the Brain
• Long term exposure to stress & violence produces high level of fear hormone, cortisol (reduces connections & may shrink hippocampus (memory)) • Children of neglectful mothers are more socially withdrawn, inattentive, cognitively under achieving in elementary years • High stress homes, & multitasking technology (computer games) more often produce short attention (ADHD) • Physical, verbal (repeated yelling, scolding, criticism), sexual abuse is related to decrease in working memory in adulthood • Children sexually abused are 4.3 times more likely to develop antisocial disorder

Effects of early abuse & neglect on the developing brain • May increase “limbic irritability” producing abnormal EEGs associated with self destructive behavior & aggression • • • • Repeated recollection and obsessing can intensify the stress effects Stress tends to short-circuit frontal lobe processing (what little there is) and switch to emotional processing (resulting in over-sensitivity) Such impairments may make the challenges of school even more stressful – a vicious cycle Children globally (rather than chaotically) neglected have enlarged ventricles or cortical atrophy Children globally (rather than chaotically) neglected have enlarged ventricles or cortical atrophy

Serotonin (neurotransmitter)
• Serotonin orchestrates other inhibitory systems in the brain to control pain, fear, and impulsive behavior; it is essential for self control • Abnormally low serotonin is related to Intermittent Explosive Disorder, impulsive control disorders (e.g., violent suicide, fire setting), Type-2 alcoholics (mean drunks), hypoglycemia, and high risk for multiple addictions • Ability to form intent is poorly developed or absent; equally high violent offenders who premeditate acts have normal or high levels of serotonin • Low serotonin and Type-2 (early onset) alcoholics are not affected by punishment • Substance abuse (e.g., cocaine) reduces serotonin release & leaves the limbic systems (emotional arousal) hyperexcitable. Even with minor provocation, irritability can rapidly spread (kindling effect) http://www.death-penalty-mitigation.com/biology-of-violence.html

Mental Defect Disability or Intention?: The “Serotonin Defense”
• 1998 case of State v. Sanders, 2000 WL 1006574 (Ohio App. 2d (2000).) Dion Wayne Sanders shot and killed both grandparents in a rage. Serotonin levels were lower than 88% of normal males • Other Serotonin Defense cases: • State of Tennessee v. Garland Godsey • State of Kansas v. Jeffrey Hebert • State of Tennessee v. Derek Payne

Risk Taking Teens: What (how) were you thinking!?
• • • • • • • About 60% of teens engage in potentially dangerous behavior The drop in dopamine levels decreases the ability to experience pleasure To obtain pleasure, more stimulation seeking occurs: drug and alcohol abuse, extreme sports, slasher movies, speeding, high-risk sex Teens show less brain activity in areas of the brain that motivate them to receive rewards (right ventral striatum) Compared with adults, they seek easier means to gain rewards (e.g., recklessness & drugs They have difficulty maintaining focus on long term goals They take higher risks with peers than when alone

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Synapse formation in the frontal cortex are over produced until just before puberty (11 girls, 12 boys), then are pruned Excess connections means they have trouble tracking multiple thoughts & focusing attention The gray matter is thinned at 1-2% per year (up to 50%!) as excess connections that are not used are eliminated Ability to learn languages declines after age 12 (changes in the corpus callosum fibers) At this age, teens begin deciding what they want to do and how they want to spend time – if it is laying around and watching TV, the other potentials get pruned. What you do is what you get good at.
Pruning increases the efficiency and power of brain function by myelinization of nerves making them respond faster Pruning may expose latent problems such as ADHD, Tourette’s, and schizophrenia
Dark areas show portions of gray matter pruned between adolescence & adulthood

…instead they rely on their emotional brain
Brain CEO: Forebrain or Prefrontal Area
• • • • • • • • • • • • • • • • • Planning Attention Judgment Reflection Prioritizing Self control Strategizing Sequencing Anticipation Organization Impulse control Second thought Working memory Modulating mood Response flexibility Goal-directed behavior Foresee consequences

Reduction in Prefrontal Gray (thinking) Matter • 22.3% gray matter reduction in psychopaths compared with controls • Total psychopathy as well as arrogance/deception, affective, and impulsive/unstable factors are all affected • Chronic liars showed 22-26% increase in white matter & 36 42% reduction in gray- white prefrontal ratios
Volumetric studies of gray matter http://www-rcf.usc.edu/~raine/volume%20reduction%20in%20unsuccessful%20psychopath.pdf
http://cat.inist.fr/?aModele=afficheN&cpsidt=17189980

• Gage was a railroad construction supervisor in 1848 when a 3½-foot 13 lb tamping rod was driven through his skull by an explosion. He was knocked down but remained conscious and returned to work about 9 months later • The tamping rod severed the connections in the left hemisphere, frontal area.

What would you predict?
• Prior to the accident Gage was described as moral, hardworking, sensitive, conscientious, intelligent, capable, shrewd but well liked businessman • Following the accident, his personality changed: he was impatient, capricious, lying, swearing, fighting, drinking, extravagant, seizure prone, and antisocial

Corpus Callosum: The connection • • • • • Connecting L and R hemispheres, it is related to creativity, higher types of thinking, intelligence, consciousness, and self awareness It changes throughout childhood and takes different shapes for different childhood illnesses; full maturity in 20s Its increasing elaboration can help learning finally “click,” such as insight Abused children have smaller corpus callosum and poorer integration between the hemispheres, and can be related to poor emotional regulation, cause-effect thinking, recognition of emotions in others or expression or own emotions, and conscience ASP showed >white matter volume, >collosal length, < collosal thickness, & >connectivity between hemispheres (Raine, et al., 2004). Larger volume is related to >affective & interpersonal deficits,
Undersocialized subjects have more difficulty than control subjects in naming the color, suggesting frontal lobe involvement (Waid & Orne, 1982)

Conflicting messages – mirror drawing apparatus
Help parents (and staff) appreciate learning disabilities and related perceptual conflicts that are similar to delays in brain development

Iowa Gambling Task: Don’t they know they’re losers?
Task: Choose a card to win game money. Decks vary in payoff: some pay constant low reward, while others pay high but also have large penalty.
• Healthy Ss stay with “good decks” while ASPs stick with “bad decks” even when they know they are losing overall • Healthy Ss show GSR stress response long before they consciously recognize losing; ASPs never develop this reaction to pending punishment • Impairment related to orbito-frontal dysfunction (the “oops” spot) • ASP shows hypersensitivity to reward and hyposensitivity to punishment • They may not be able to learn social conventions associated with loss and gain

Prisoner’s Dilemma: Cooperate or betray?
• Persons scoring higher in psychopathy more often betrayed their partners (big surprise!
– useful for law enforcement) • They showed less amygdala (fear) activation suggesting weaker aversive conditioning • People with low psychopathy have to work harder to betray peer; psychopaths have to work hard not to betray – they are self-serving (Rilling, J. K., Glenn, A. L., Jairam, et al., 2006)

Tower of Hanoi/London Task
• Measures complex planning, ability to analyze a problem, devise a strategy, monitor one’s performance, & modify strategy as needed • Antisocials are less able to maintain a plan and inhibit irrelevant information (Pham, et al., 2003) • Also assesses working memory and can reflect FAS/FAE • Only one disk may be moved
at a time.
• Each move consists of taking
the upper disk from one of the pegs and sliding it onto another peg, on top of the other disks that may already be present on that peg.
• No disk may be placed on top
of a smaller disk.

Mirror neurons: Monkey see, monkey do
• Newborns as young as 72 hours old can imitate some facial expressions • A mirror neuron is a neuron which fires both when an animal performs an action and when the animal observes the same action performed by another • mirror neurons have been found in the premotor cortex (motor behavior) and the inferior parietal cortex (distinguishing self/other) • These appear to be involved in understanding intentions of others, empathy, predicting actions of others, and social bonding • Such empathy usually prevents us from causing discomfort to others (Blair’s theory of Violence Inhibition Mechanism)

Poor recognition of emotional cues (impaired empathy)
Conduct Disordered Youth : • When reading emotion, teens rely more on the amygdala (L), while adults rely more on the frontal cortex (R).
• Errors in evaluating motive and intent (even normal teens are 2x that of adults) • Misinterpret social cues & attribute hostile intentions • Tease others but respond negatively to others • Abnormal standards and expectations regarding own behavior • Impairment in deep emotional relationships (that come from reading cues) • Less amygdala activity in response to viewing fearful faces than normal Ss • Less communication between amygdala and ventromedial prefrontal cortex (processing of fear and moral reasoning)

Recognizing emotions & callous-unemotional characteristics
• The amygdala responds to cues that elicit emotions; it helps recognize scary faces and helps us generate a fear response or have empathy toward others • Less communication between amygdala and ventromedial prefrontal cortex (process fearful experience & moral reasoning)
S.P. had damage to amygdala. She was asked to rate how well six faces expressed different emotions (compared to 20 normal volunteers)

Faulty Facial Processing by adult psychopaths
• fMRI tested 9 normal and 6 criminals in their response to joyful & neutral, and fearful & neutral facial expressions • Normals showed increased activity to happy faces compared to neutral faces in the recognition area of the brain (fusiform visual area) • Normals showed reaction to distressed sad and fearful faces, while psychopaths showed even less activity than when they viewed neutral faces • Conclusion: the neural pathways that are supposed to process human emotion are either non-functional or are processed differently – psychopaths don’t identify with the emotional
stress of their victims
Deeley Q, Daly E, Surguladze S, Tunstall N, Mezey G, Beer D, Ambikapathy A, Robertson D, Giampietro V, Brammer MJ, Clarke A, Dowsett J, Fahy T, Phillips M and Murphy DG (2006). Facial emotion processing in criminal psychopathy. Preliminary functional magnetic resonance imaging study. British Journal of Psychiatry, 189, 533-539.

First-person shooter: who plays video games?
Lots of teens play, but most are not adversely influenced into antisocial behavior

Brain and violent media
Observation of media violence Encoding of aggressive scripts Greater interest in media violence Fantasy rehearsal of behavior & scripts Increased accessibility of aggressive scripts from practice Greater identification with aggressive media characters Frustration and situational readiness to aggress Decreased popularity Lower academic achievement Aggressive reactions to interpersonal conflicts
http://www.mediaculture-online.de/fileadmin/bibliothek/murray_violentface/murray_violentface.html

1. Children are more likely to imitate the actions of a character with whom they identify. In violent video games the player is often required to take the point of view of the shooter or perpetrator.
2. Video games by their very nature require active participation rather than passive observation.
3. Repetition increases learning. Video games involve a great deal of repetition. If the games are violent, then the effect is a behavioral rehearsal for violent activity.
4. Rewards increase learning, and video games are based on a reward system. • Exposure to violent games increases physiological arousal • Exposure to violent games increases aggressive thoughts • Exposure to violent games increases aggressive emotions • Exposure to violent games increases aggressive actions • Exposure to violent games decreases positive prosocial (i.e., helping) actions

Repeated viewing of violent programs reduces activity of violence control areas:
• right lateral orbitofrontal cortex (impulse control) • Amygdala (fear, anger) • After viewing violence the areas associated with planning aggressive action became more active
The yellow area of the brain is the right lateral orbitofrontal cortex, or right ltOFC, which has been previously associated with decreased control over a variety of behaviors, including reactive aggression. The graph illustrates that as the number of violent movies watched increased (stimulus number along bottom of graph), the right ltOFC activity diminished.
• These changes did not occur when Ss viewed movies with non-violent scenes but had horror or physical activity
Columbia University Medical Center (2007, December 10). This Is Your Brain On Violent Media. ScienceDaily.

Lights aren’t on and no one’s home…
Empathic response to violent images in psychopaths Telling images: These scans show brain activity in empathy generating centers of the limbic system in normal individuals (left) and in psychopathic individuals (right) when they are exposed to violent images. (Department of Clinical and Cognitive Neuroscience, University of Heidelberg)

“That was funny!”: Bullies enjoy the pain of others • Aggressive youth were shown clips of a pianist having fingers pinched by closing the piano lid on them • Areas related to processing pain were activated, but… • So were the amygdala and vertral striatum (reward centers) • Unlike unagggressive youth, aggressives did not activate medial prefrontal or temproparietal junction associated with self regulation (impulse control) • Youth without aggression problems did not show the same activation, but instead it evoked empathy
http://huehueteotl.wordpress.com/category/science/neuroscience/

Impulsiveness
• Swift action without forethought or conscious judgment • Related to risk taking, lack of planning, and making up one’s mind quickly • Not focusing on the task at hand and acting on the spur of the moment • Decreased sensitivity to negative or long-term consequences

ADHD

Easy to start…not so good at stopping
As part of the impulsivity of ADHD, kids have normal ability to say “GO” at the neurological level, but their ability to say “NO” or “STOP” comes just a fraction of a second slower. As a result, they react before thinking and without much self-control

The Post-It Notes of the brain: Working Memory • WM is the “mental workspace for storing & manipulating information – learning potential • Related to literacy & math (and academic failure in these) • Difficulty in problem solving • Difficulty in cause-effect thinking, seeing potential consequences • “Goes in one ear and out the other”
4 x 3 + 6 - 2

The “Oops” Center– anterior cingulate gyrus
• The cingulate is responsible for helping focus attention • Links cingulate and emotional hippocampus for integrating reason & emotion to guide decisions • Undergoes high myelination (doubles) during adolescence • “Oops center” anticipates risk, detects and keeps us from making errors • May involve ability to empathize— may not be able to recognize and appreciate other’s feelings until mid to late teens

Sample ADHD Dynamics & Conduct ADHD Out of seat, bother others Hyperactivity Impulsive: act before thinking Inattention, poor concentration Poor working memory, slow processing Make mistakes Misread social cues Difficulty learning, get behind Get in trouble Discipline Feel it’s unfair Unpredictable relating Peer avoidance rejection Resentment Act out Repeated failure Default to delinquent peers Non attendance Withdrawal Embarrassment, frustration, discouragement Defiance

…Another continuum?
What are the requisites for choice: • Awareness of the situation • Ability to see cause-effect sequences • Anticipation of consequences (access memory) • Acceptance of personal responsibility • Aware of alternatives • Estimating & comparing possible outcomes • Acknowledgement of unsatisfactory outcomes • Decisiveness (making a choice) • Persistence of effort in executing behavior • Open to feedback for revising behavior
Impulsive
Unconscious, spontaneous, reactive
Compulsive
Automatic, repetitive, addictive
Deliberate
Intentional, manipulative, deliberate

Deconstructing Choice Memory Ability & willingness to reflect on outcomes Self efficacy & previous experience Awareness of the situation Acknowledge one’s role as participant Awareness of need for choice Awareness of options Available criteria for selecting options Outcomes Willing to make decision Plan of action Opportunity to act Act Able to see consequences of (not)choosing Sustained attention & freedom from distraction Logical/sequential thinking Cognitive complexity Working memory Reflective ability Verbal fluency

Mechanism
Impaired (working) memory Attention span/distractibility Mood lability Mood lability Poor primary processing Lack of empathy Theory of mind Narcissism Deny personal responsibility Poor time perception Poor cause-effect thinking
Effect on choice
Disruption of information input, storage and retrieval Rapid reaction
Treatment
Memory techniques Smaller chunking Medication Emotional reaction Act before thinking Disregard for/ignoring impact on others Interruption methods Behavioral rehearsal Time out Medication Cinema therapy Role Playing & reversal Identification with others No reason to change behavior Unaware of patterns Disconnect behavior & consequences, no anticipation Cause-effect chains/ladders Positive & negative role RBT’s ABCs Time-line drawing Picture Arrangement Story Telling Cause-Effect chains/ladders

Key Points
• Some bad behavior is not due to bad choices but to impulsiveness & compulsiveness • Some behavior is not for the motive of getting attention, but it can get attention • Some conduct disorders are related to delayed brain development and subsequent brain function • Choice is a complex series of cognitive and affective events that may not all be present • The mechanisms of choice can be promoted within limits of brain development and integrity • Many simple techniques can be used to build the mechanisms and self regulation skills

The Brain and Ethical Reasoning: The lesser of two evils
“You are standing next to a switch in a trolley track and you notice that a runaway trolley is about to hit a group of five people who are unaware of their danger. However, if you switch the track, the trolley will hit only one person. What do you do?”

“You are standing on a bridge over a trolley track beside a single person. Again you notice that the runaway trolley is headed toward five unaware people. Do you push the single person onto the track to stop the trolley?”

Ventromedial Cortex

The amygdala is 17% smaller in psychopaths Normal people show fear, startle, and avoidance reactions to painful stimuli – psychopaths don’t

Non-reactivity to Emotional Stimulation Antisocials react to horrific pictures the same as they do to neutral pictures

Poor discrimination between emotional & non-emotional cues
Persons with high affective interpersonal psychopathic traits (e.g., superficiality, manipulative, charm, lack empathy) show reduced GSR to both pleasant & unpleasant sounds (Verona, et al., 2004)
Laughter Screaming

• “You're climbing into bed when you see a huge spider on the covers” • “You're taking a shower alone when you hear someone breaking into your house” • “You're in the dentist's office, waiting for a root canal” • Psychopaths show much lower responses to fear-provoking sentences than non-Ps; defective processes that normally elicit emotions • This accounts for their reckless, impulsive lifestyles • Helps explain why verbally-oriented approaches that rely on language-affect connections (e.g, counseling) are so ineffective with this group Patrick, et al., (1994)

Key Points in Brain Research
• Use it or lose it– the brain begins pruning unused areas during pre-adolescence • The brain, especially higher functions, is not complete until about age 24 • Brain development is often delayed or impaired in ASP, leading to impulsive behavior and emotional reactions • ASPs “think” emotionally and impulsively, not rationally • They may be able to demonstrate “logical” thought in normal interaction, but they drop out details when goal directed • ASPs are not particularly deterred by pain, threats, or punishment • In many cases, they just do not see the consequences or how their behavior is self defeating • They may be oversensitized to being offended and under sensitized to certain facial expressions (e.g., fear & sadness)

Some important cautions
• Clearer understanding of brain function and behavior are emerging often and change previous understanding – current understanding is still tentative and in some cases controversial • Although we can indirectly identify certain areas of the brain involved in behaviors, the brain acts as a complex system of connections • Being able to identify some neurological correlates of behavior does not imply our being able to control such behavior, not does it mean that such behavior is uncontrollable • It is unclear how much ASP increases risk for brain dysfunction (e.g., substance abuse, head injury), and how much injury contributes to ASP • Many people with conduct problems often have co-existing disorders that are difficult to separate • Antisocial behaviors are a combination of heredity, neurological functioning, and experience • There are no perfect predictors of antisocial behavior, especially among youth; premature labeling may predispose them to giving up on them or contributing to their behavior

The early solution…lobotomy!
• In 1966 12 year-old Howard Dully became the youngest recipient of the icepick transorbital lobotomy for: “being unbelievably defiant…objects going to bed…daydreaming…and says ‘I don’t know.’” • Lobotomy developer, Dr. Walter Freeman travelled the US in his Lobotomobile conducting up to 2500 of the 10 minute procedures in 23 states from 1936-1967

Letter from a parent…
Most of America 's populace think it improper to spank children, so I have tried other methods to control my kids when they have one of "those moments."
One that I found effective is for me to just take the child for a car ride and talk. They usually calm down and stop misbehaving after our car ride together. I've included a photo below of one of my sessions with my son, in case you would like to use the technique. Sincerely, A Friend

Sample Family System Dynamics Father’s Strict Mother’s leniency Self justification Son’s behavior issues Truancy Parental conflict Physical Withdrawal by each Verbal abuse abuse Son observes Angry about abuse Hypersensitive, reactive Frustration with school Depressed, preoccupied about situation Poor academic performance Poor concentration at school Referred for discipline Fighting with peers Defiant with teacher

Parental contribution to empathy
• Secure attachment & nurturing : responsiveness to infant, available, sensitivity, consistency • Take children seriously : respect feelings, preferences, questions • Practice cooperating : demonstrating collaboration rather than competition • Guiding & explaining : value sharing, caring, helping, explain why prosocial behaviors are important and appreciated, how aggressive and selfish behaviors harms others, intervening when child is selfish or cruel, explain how others feel • Modeling : generosity, charitable to others, practice what preached, small acts of kindness • Promoting and praising prosocial self image : encourage opportunities to experience caring & helping, view self as caring and helping, volunteering, internal rather than external locus of control for altruism

Essential Components of a Moral Self Core Empathy (2-7 yrs): see from other’s perspective Sympathy: sorrow for another person’s distress Remorse: regret & sadness at one’s role in another’s pain Anxiety (5-11 yrs): apprehension about violation of other’s standards Guilt (3-4 yrs): signal to repress impulses so not to offend or upset another; includes regret over actions Shame (1-2 yrs): Inner sense of not meeting expectations Embarrassment (3 yrs): expansion of shame involving standards of others and fear of judgment

Emotional Intelligence Skills (Goleman)
1.
• •
Self Awareness
: Knowing one’s internal states, resources, and • limitations
Emotional awareness
: recognizing one’s emotions and their effects
Accurate self assessment
: knowing one’s strengths and limits Self confidence: strong sense of self worth and capabilities 2. Self Regulation : Managing one’s internal states, impulses and resources • Self control: keeping disruptive emotions and impulses in check • • • • Trustworthiness: Maintaining standards of honesty and integrity Take responsibility for personal performance Adaptability: Flexibility in handling change Innovation: Being comfortable with new ideas 3. Motivation: Emotional tendencies that guide or facilitate reaching goals • Achievement drive: striving to improve • Commitment: aligning with the goals of the agency or group • • Initiative: Readiness to act on opportunities Optimism: Persistence in pursuing goals

4. Empathy
: Awareness of others’ feelings, needs, perceptions and concerns • Understanding others: Sensing others’ feelings and concerns • Identifying their development needs: bolstering their abilities • Service orientation: recognizing and meeting users’ needs • Political awareness: Reading a group’s emotional currents and power relationships 5. Social Skills: Ability to induce desirable responses in others • Influence: ability to persuade • Communication: listening openly • Conflict management: negotiating and resolving disagreements • Change catalyst: Initiating and managing change • Building bonds: nurturing key relationships • Collaboration and cooperation: working with others towards shared goals • Team capabilities: Creating group energy in pursuing collective goals

“You can’t make me!”-- Dealing with power struggles
• Remember they believe adults give in if harangued enough; • Give limited choices • Don’t give choices you aren’t prepared to follow though on • Don’t argue over attitude– you can’t change it or win • Make sure both parents are aligned • When you over-react, you lose!
• Focus on what matters– some things aren’t arguing • Focus on a few key rules and stick to them • When something is non-negotiable, say so and mean it • Have realistic expectations based on development and ability • Spend positive time doing what the child wants • Listen to the child’s reasoning • Don’t engage in arguing after a decision has been made • Ignore or redirect if the child follows around, argues, whines; consequences if disrespectful • Praise responsible behavior when you see it • Don’t expect oppositional behavior to disappear– they are learning • Don’t hesitate to “sleep on it” before making a decision • Use “logical consequences”– those that reasonably follow from the behavior • Use humor • Don’t scream, call names, label, use abusive language, or hit • Tell once, clearly and check hearing, then go to the logical consequence • Give them appropriate power-- a voice in family decisions The average American child receives about 13 minutes a day in actual communication with the parents. Parents spend 9 minutes of this correcting, criticizing or arguing with their child. That leaves only four minutes for anything positive to happen.

Enhancing Parental Positions Skill-building Opportunities • Parent skill training & coaching
• Remove barriers to better family functioning
(e.g., unemployment, work schedules, etc.) Clarify & structure
• Clarify and enforce parents as the top of the authority and
decision-making hierarchy in the home • Require children to ask permission before engaging in a behavior or activity or attending events • Clarify role differences and responsibilities of parents in contrast to those of the children • Reduce parental conflict and undermining of each other’s authority • Increase unification of parents as a unit
• Increase the more stable parent’s influence and control
• Increase parental follow through &consistency in discipline and nurturance • Implement family meetings so parents are less likely to be played against each other separately

Substitutes for Absent Parenting Independence
• Child’s participation in character building
and youth programming activities (e.g., sports, church group, Scouts, etc.)
• Create more structured activities programming at home • Increase activity and involvement in school activities & pride in
academic performance
• Increase self reliance & independence • Part-time work, volunteerism
Surrogates
• Provide parental surrogates including mentors, coaches, Big
Brother/Sister, etc.
• Rely more on extended family and close friends • Refer for foster parenting • Arrange for respite care when parent’s are overwhelmed

Neutralizing Adverse Parenting Effects Supervision Structure Distancing
• Supervise visitation between parents and out-placed children • In-home observation and correction of adverse parental behaviors • Regular reviews of family/parent behaviors by Human Services • Use video monitoring as a feedback system for behavior change • Reduced family isolation to encourage greater reliance on outside
supports
• Remove parent’s control over needed resources • Clarify rules and consequences to minimize inappropriate punishments
resulting from parent’s unclear rules
• Restrict visitation, restraining order • Increase child’s understanding of the limiting factors in parent’s mental
illness or substance abuse (not personalize the parents pathology)
• Spend more time away from home in constructive activities (e.g., clubs,
organizations, team sports, etc.)
• Spend more time with healthy extended or surrogate families • Decrease child’s expectations regarding parent’s broken promises and
threats

Components of Empathy Enhancement for Juvenile Offenders
• • • • • • • • Ability to identify and express emotions Development of good listening skills in order to be able to identify feelings of others Address lack of awareness of the devastating short and long term emotional impact that the behavior had on the victim(s); Constructing a series of apologies to his victims Identification of feelings prior to, during and after offenses; address lack of remorse Comprehension of how anger, stress and values influence their reactions to others Modification of behavior out of concern for others’ feelings Dealing with own victimization Reinforcement of prosocial behaviors (4:1 ratio) Questionable if client is older teen, repeat offender, psychopathic & sadistic indicators, poor response to treatment

Traditional vs. Sex Offender Treatment Traditional
• client not responsible for behavior • supportive • trust client • believe client • allow client to set agenda • follow client’s values • work to alleviate guilt • client welfare is first concern • complete confidentiality • goal to remove negative feelings • concern how client feels • client is accountable to self
Offender Tx
• client is responsible for behavior • confrontive, challenging • do not trust client • expect lying, denial, minimizing • therapist sets agenda • therapist imposes values • works to induce guilt • public safety is first concern • limited confidentiality • induce negative feelings around behavior to motivate • concern about behavior • client is accountable to society

Traditional
• families refer for members in need of help • initial outpatient Tx is effective & least restrictive • individual treatment is usually effective • therapeutic relationship stops at the door • Tx terminates if client is unwilling to cooperate
SO Tx
• families also deny, minimize, & resist Tx • client may not have ability to control impulses • less disclosure & more lying occurs in individual Tx • strong collaboration among stakeholders is required • client returns to judicial system if uncooperative

“Outta the Blue!”: Deconstructing actions 1. What happened in (focus on the suddenness) 2. Elaborate on the detail and start mapping 3.
Columbo Mode: “What happened just a second before that?” 4.
…and just before that? (focus on details of thoughts, feelings, and behaviors) 5. Ask if the map accurately describes the sequence 6. What might happen if it were stopped at each critical step?
7. Practice re-enactment. Start to escalate, then stop and examine (practice interruption)

Teaching impulse control • “Stop! Think! Act!: use at every opportunity, graphic posters, strong verbal praise • Slow down: time out, count to ten, 3 deep breaths, “warmer—colder”, muscle relaxation • Problem solving puzzles, mazes, manipulative puzzles (e.g., “tavern puzzles, Tower of London) • Lead the child through the problem solving process (don’t just direct or tell) • Teach awareness: “Instead of “leave me alone & sit down” try “what do you see me doing now? Do you think this is a good or bad time to ask me a question? What should you be doing?
• Behavior shaping: giving small, tangible rewards for cooperation with external control of impulsivity. “You can one M&M now or five if you wait til I finish.” • Model impulse control and show how to discuss thoughts and feelings

Covert Sensitization
1.
2.
3.
4.
Clearly identify the target scene: Client imagines himself engaging in the undesirable behavior. • • • • Identify the aversive imagery: When vivid, inappropriate imagery is switched to an aversive consequence associated with the behavior Parental shock & hurt Police arrest Court trial Peer rejection The purpose is to build up an aversion to what previous was an attractive stimuli The client does not have to engage in the behavior, only imagine it

Medication for antisocial behaviors
• Antidepressants • SSRI (Prozac, Zoloft, etc.): reduce depression, anxiety, OCD, mood swings • Tricyclics (e.g., Elavil, Tofranil): psychotic depression & ADHD • MAOI (e.g., Marplan, Nardil): anger control, impulsivity, interpersonal sensitivity, social anxiety • Lithium: reduce impulsive, anger, combativeness, explosive, & emotionally unstable behavior (esp. bipolar mood swings) • Benzodiazepines (e.g., Xanax, Klonopin, Valium): control anxiety & insomnia, episodic aggression (potentially addictive) • Psychostimulants (e.g., amphetamine, methylphenidate): ADHD • Anticonvulsants (e.g., Carbamazapine): episodic (limbic) dyscontrol including angry outbursts, violence, & self-mutilation

Medication risks include:
• Time to reach therapeutic levels • Interaction effects with illicit drugs • Side effects & toxicity • Dietary restriction with MAOI • Hoarding drugs for overdose • Substance abuse or relapse • Selling medications • Defiance & noncompliance • May require close medical supervision • Only for symptomatic treatment

The frog & the scorpion: A psychopath parable

Possible pathways among traits (& potential intervention points) High pain threshold Limited cognitive capacity, inattention Poor social attachment Low fear, anxiety Inability to anticipate, learn, insight Impulsiveness Poor identification with others Narcissism grandiosity Verbal fluency Stimulation seeking Low motivation to anticipate consequences Poor planning, present orientation, unrealistic Early behavior problems No remorse, shame, guilt, embarrassment Charm glibness Opportunist (versatility) Offending Parasitic Irresponsible Aggressive Callous Superficiality Promiscuity Short term relations Manipulation Lying

Amenability: Requirements of Treatment Timeliness
• willing to attend treatment • regular attendance • timely attendance • remains during session
Personal Acknowledgement
• acknowledge problem • shows concern about the problem • admission of guilt • take personal responsibility • admits impact on others
Goal Orientation
• can formulate goals • can formulate specific behavioral objectives • prioritize goals • attaches value to goals
Disclosure
• discloses personal information • discloses sensitive information • discloses previously unknown information • expression of feelings • expression of thoughts, beliefs, attitudes
Ability to Relate
• able to engage with therapist • self disclosure of historical information • trusts therapist
Socialization
• identification • empathy • guilt • shame • embarrassment • remorse
External response
• compliments • encouragement & support • impact on others • conforms to rules • responds to direction • able to be distracted or redirected • responds to discipline & consequences
Persistence
• accepts treatment homework assignments • completes homework assignments • comes prepared for sessions • reports homework assignments • persistence in examining difficult issues

Traditional treatment difficulties with psychopaths
• Low motivation to change • Noncompliance with requirements & rules • Low empathy, remorse, guilt • Lack of insight into affective state • Avoidance of personal responsibility • Superficial relationships; lack therapeutic alliance • Noncompliance and disruption of others’ Tx • Tend to focus on primary goal & ignore peripheral & cost/benefit
reasoning
• Noncompliant with or abuse medication • Less reactive to punishment • Lack of understanding of antecedents of behavior make relapse
prevention strategies difficult
• Cannot trust self-report, deceptive, manipulative

The higher the psychopathy, the higher the recidivism risk
30-67 month period http://www.csc-scc.gc.ca/text/pblct/forum/e052/e052h-eng.shtml

Implications of psychopathy for law enforcement & corrections
• Juvenile diversion, early intervention, and family intervention programs are the best hope to reduce offenders • Build respectful relationships with youth though opportunities for positive rather than negative interactions • Much juvenile offender behavior is triggered by incidents at home • Avoid arguments about intention, motivation or denial; focus on behavior & consequences • Appeals to empathy and threat of punishment may not be effective with youth with psychopathic features • Expect the unexpected– they don’t respond to reason and act impulsively even when it is clearly to their disadvantage • Antisocials may “age out” but psychopaths and pedophiles continue with high risk behavior throughout their lives • Some psychopaths are consummate liars and extremely difficult to detect; consistency in behavior is a better measure

The Great Escape…
• Offenders classed as psychopathic were around 2.5 times more likely to have been given a conditional release than undiagnosed offenders; • psychopathic sex offenders were 2.43 times more likely to have been released than their non psychopathic counterparts, • psychopathic non sex offenders were 2.79 times more likely to have been released than non psychopathic counterparts.

: when high school students were shown a date rape scenario--
• 59% indicated having done something similar • 33% expressed some likelihood of raping • 66% believed the rape was the victims fault • 40% believed that in spite of the resistance, the woman wanted
forced sex
• 20% believed that “roughing up” sexually excites a woman • 17% said that such force is the only way to arouse a “cold”
woman
• 17% reported that going home with a man is consenting to sex • 11% said that getting drunk at a party makes a woman “fair game”

Effectiveness of Corrective Thinking • • • • • •
High risk clients
66% reduction in crime for those who completed the program.
33% reduction in crime for those who entered but did not complete.
48% of all clients pursued no new crime.
29.4% exhibited a decrease in crime.
6.4% showed no change.
15.6% exhibited an increase in crime.
• • • • • Average number of criminal charges: Reduced by slightly over 50% for all clients who entered the program.
Reduced approximately 66% for those who completed the program.
Reduced by approximately 33% among clients terminated before completion.
Reduced 79.17% for those who completed and had no previous arrests.
Reduced 36.36% for those who terminated prior to completion with no prior arrests.
Truthought's Corrective Thinking Treatment Model includes four studies done by University of Wisconsin, US Department of Justice National Institute on Corrections, US Department of Justice Bureau of Justice Assistance (1988-1993)

Key Points in Treatment
• Early intervention (childhood) is more effective than later (adolescence and adulthood) • Multimodal approaches are more effective than singular approaches • Minimize manipulation by frequent collaboration among parents & providers • Decreasing family pathology & increasing competent parenting is essential for youth • Empathy training works with younger clients and those who are more socialized; less well with callous & remorseless clients (may actually increase recidivism) • Hold clients to behavior change, not just participation in and completion of a program • ODD, CD, and ASP respond to treatment, but no effective treatment has emerged yet for the psychopath

Protective Factors
Environment
• Middle or upper class • Low unemployment. • Adequate housing. • Pleasant neighborhood. • Low prevalence of neighborhood crime. • High-quality healthcare. • Easy access to adequate social services. • Flexible social service providers who put
clients’ needs first.
Family
• Adequate family income. • Structured and nurturing family. • Parents who promote learning. • Fewer than four children in family. • Two or more years between the birth of
each child.
• Few chronic stressful life events. • Multigenerational kinship network. • Nonkin support network. • Warm, personal relationship with parents(s)
and/or other adult(s).
• Little marital conflict. • Family stability and cohesiveness. • Plenty of attention during first year of life. • Sibling as caretaker/confidante. • Clear behavior guidelines.
School
• Schools that promote learning,
participation, and responsibility.
Individual
• Positive early development. • No emotional or temperamental
impairments.
• Physically healthy. • Highly intelligent. • Positive personality characteristics, such
as being affectionate, autonomous, adaptable, having a positive outlook, and exercising self-discipline.
• Adequate problem-solving skills. • Appropriate social skills. • Learned to do one thing well that is
valued by themselves, their friends, or their community.
• Able to ask for help for themselves. • Able to bond with a socially valued,
positive entity, such as school, community group, church, or another family.
• Can distance themselves from their
dysfunctional families, so the family is not their sole frame of reference.
• Interactions with a caring adult who
provides consistent, caring responses.

Juvenile Sex Offenders

http://www.lao.ca.gov/2008/crim/inmate_education/inmate_education_021208.aspx

Effectiveness of interventions for Serious & Violent Offenders
Positive effects, consistent evidence
Noninstitutionalized Offenders
Individual counseling, interpersonal skills, behavioral contracting
Institutionalized Offenders
Interpersonal skills, teaching family home Less consistent positive effects Multiple services, restitution, probation & parole Inconsistent but generally positive Employment related programs, academic programs, advocacy, family & group counseling Inconsistent weak or no effects Reduced caseload, probation & parole Cognitive behavioral treatment, community residential programs, multiple services Individual counseling, guided and group counseling Employment related programs, drug abstinence, wilderness programs Consistently weak or no effects Wilderness challenge, early release, deterrence and vocational programs Milieu therapy http://www.surgeongeneral.gov/library/youthviolence/chapter5/sec5.html

Roundtable Discussion
• Briefly introduce yourself and the kind of work you do
related to our topic
• What most surprised you about the topic? • What was most interesting? • What will be most useful—how can you apply it in
some way?