Signs of trouble ahead

The first year of a child’s life is crucial to the process of forming social attachments that provides a pattern for future healthy relationships.

But when the attachment process fails the child has difficulty in perceiving and understanding the emotions of others.

The biological and emotional effects of trauma on the developing mind and the importance of the primary caregiver in enabling the young child to develop the ability to be reflective are well known.(1)

For example, my work with adults who score high on Hare’s revised psychopathy checklist, the standard measure for assessments, found that those perceived as “hard men” in prison may be vulnerable to psychic trauma. They may have learned in childhood to create a psychopathic defence as they are too vulnerable to deal with the traumas of everyday life. For although others in the same social environment may feel “contained and safe”, they may perceive the world as a continuous war zone.

This understanding can provide an insight into developing more appropriate interventions for children to help them understand themselves better and hopefully make better choices.

Assessment must be accurate and needs to explore other explanations for a child’s behaviour and co-presenting conditions, such as post traumatic stress disorder, dissociative disorders, attention deficit hyperactivity disorder, or early signs of personality disorder.

I would advocate caution at identifying traits associated with severe conduct disorder (SCD), as all too often when following up this diagnosis, I have found that their behaviour has been linked to past experiences of trauma and their symptoms are consistent with dissociation and acute trauma.

SCD can be described as a marked life-long attitude of being “self-centred”: taking what one wants, when one wants it without any regard for the feelings and rights of others.

The diagnosis has 15 symptoms that fall into four sets: aggression to people and animals; destruction of property; deceitfulness or theft; and serious violation of rules. Of the 15 symptoms, at least three have to have occurred in the past 12 months.

SCD is found in 8 per cent of boys and 3 per cent of girls.(2 )Juveniles with SCD can commit many of the severe crimes seen in society that cause significant harm to others such as forced sex, physical cruelty, and use of weapons. In early childhood it can present as the child being aggressive, disruptive, unloving, cruel, and defiant to caregivers, educators and others.

Due to these behavioural traits it can lead to peer rejection, which can set the stage for involvement with deviant peers.(3) This environmental shift can lead to delinquency, school dropout, internalising problems, adolescent pregnancy and drug and alcohol use.

A particular group of rejected children who overestimate their social acceptance may be at particular risk for aggression. Although aggression is common during the early stages of development – at 18 months of age, 60 per cent of boys and 30 per cent of girls hit their peers – the frequency of this aggression steadily decreases from the age of two to 12 years.

But up to 10 per cent of children with SCD continue to have high levels of aggressive behaviour. These children who are chronically aggressive are also at greatest risk of displaying the most delinquency, substance abuse and having school difficulties during adolescence.(4)

The adult equivalent of this disorder is severe antisocial personality disorder. Adult offenders with this disorder have psychopathic traits (egocentricity, shallow emotions and an absence of empathy, anxiety and guilt). But it is still not clear if psychopathy can be reliably assessed in the youth population, but a sub-group of young people with SCD exhibit callous unemotional traits.

And the antisocial screening device, which has been adapted from Hare’s psychopathy checklist, has been used with adolescents to assess callous unemotional traits.

The features of SCD are:

* High rates of aggression.
* Age of onset before 10 years old and persistent into adulthood.
* High rates of co-morbidity.
* More likely to be solitary or isolated (no intimate relationships, associates but not friends).

So, for SCD to be detected practitioners need to assess core symptoms and behaviour in relation to age and attempt to gain information from sources starting with the parents, teachers, and young people themselves.

Risk factors for childhood onset of SCD include parental antisocial behaviour; parental substance abuse; low IQ; sexual abuse; limited or lax parental supervision; and harsh discipline (and abuse). Social risk factors include low social economic status and lower maternal education.

Most evidence-based interventions are not only intensive but require being comprehensive, multi-focused and multi-disciplinary. These approaches are viewed as being better at controlling the undesirable behaviour than actually changing attitudes or increasing social values.

There is at present no simple or surefire fix to the problem of SCD and most interventions need to be in place for months or even years. Shock treatments, peer counselling and boot camps don’t work.

Treatments that do work or have some positive outcome tend to be behavioural. They can be skills-oriented as in anger management and moral reasoning; they can be programmes with family-based components such as parent training, family therapy, and couples therapy. Treatment of parent and child interactions and therapeutic communities are also feasible.

Research is starting to provide an insight into detectable behaviours that might indicate SCD. Therefore treatment could be directed towards the following areas: children who start fires, carry out graffiti, are sexual offenders or have been sexually abused, or who routinely steal.

Early conduct disorder problems have long-lasting effects that can affect us all in terms of crime, mental health, sexual outcomes, education and employment. With the possible exception of IQ, no other factor present during childhood has as far-reaching consequences in terms of development.

Richard Cross is a UK Council for Psychotherapy-registered psychotherapist who has worked with high-risk adolescents for many years. He was the co-author of a therapeutic programme for antisocial youth for the New Zealand Corrections Department, which is used with high-risk adolescent offenders. He currently works for CareVisions Group, which provides therapeutic residential care for children in the UK.

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This article discusses the need to implement a strategy of support and intervention for children with severe conduct disorder. Although it is not clear whether psychopathy can be assessed in a young person, looking at adult psychopathic behaviour provides an insight into providing interventions for young people displaying similar traits.

(1) P Fonagy, Affect Regulation, Mentalization, and the Development of Self, Other Press, 2002
(2) D Offord, M Boyle, Y Racine, “The epidemiology of antisocial behaviour in childhood and adolescence”, In DJ Pepler (ed) The Development and Treatment of Childhood Aggression, pp 31-54. Hillside, N J Erlbaum, 1991
(3) J Lochman, H Dane, T Magee, M Ellis, D Pardini, N Clanton, “Disruptive behaviour disorders: Assessment and intervention”. In B Vance (Ed) The Clinical Assessment of Children and Youth Behaviour: Interfacing Intervention with Assessment, pp 231-262, Wiley, 2001
(4) D Nagin, R Tremblay, “Trajectories of boys’ physical aggression, opposition and hyperactivity on the path to physical violent and non-violent juvenile delinquency”, Child Development, 70, pp 1181-1196, 1999

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