The Psychopath Whisperer: The Science of Those Without Conscience (21 page)

DSM-III
was the first edition of the
DSM
to include an operational definition for conduct disorder, and the criteria for conduct disorder have fluctuated substantially ever since.
Conduct disorder
was originally defined as repetitive conduct in which the rights of others are violated, including physical violence against persons or property.
DSM-III
was heavily influenced by behaviorist theory, and as such, environmental influences played a prominent role in describing the two subtypes, the Undersocialized type and the Socialized type. The “undersocialized type” included children who fail to establish normal degree and quality of affection, empathy, or social and romantic bonds with others. In contrast, the “socialized type” was able to develop normal attachments with others but still got in a lot of trouble. These groups were based on taking all the symptoms of disruptive children and conducting what is known as
factor analyses
, dividing the symptoms, statistically, into two categories.

DSM-IV
dropped the distinction between the undersocialized and socialized subtypes. Now the undersocialized group is known as
early age of onset group
. Poor parental monitoring now plays an important role in assessing conduct disorder. Research shows that youth who have greater interpersonal problems at an early age as well as other psychosocial risk factors (i.e., poor parenting) have more stable antisocial traits into adulthood.

DSM-IV
listed four general conduct disorder categories: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. For a child or youth to receive a diagnosis, at least three of fifteen symptoms from these headings must be present for at least twelve months.

In reviewing what we know of Brian’s and Eric’s histories, we can see that both Brian and Eric meet criteria for
severe
conduct disorder, childhood-onset type. And since they meet criteria for this more severe disorder, psychologists would not give them the lesser diagnosis of oppositional defiant disorder (even though they meet most of the criteria).

What does the conduct disorder diagnosis mean? Is it the precursor to a diagnosis of psychopathy as an adult? Well, it’s actually not that clear. The diagnosis of conduct disorder is exclusively based upon observable behaviors; it does not assess any of the emotional, interpersonal, and affective traits associated with psychopathy. In fact, there is no mention of lack of empathy, guilt or remorse, or shallow affect in the
DSM-IV
conduct disorder diagnosis. Many scientists have argued that the failure to include such
callous and unemotional
traits in the diagnosis of conduct disorder severely limits its utility. And there are additional criticisms of the conduct disorder diagnosis. Nearly 80 percent of children diagnosed with conduct disorder grow out of it and do not develop an adult personality disorder or psychopathy. This would suggest that conduct disorder is not really a disorder at all. In other words, the diagnosis does not predict which kids are on a trajectory toward lifelong personality problems, future antisocial behavior, or psychopathy.

Perhaps the most poignant criticism of the conduct disorder diagnosis comes from the former president of the American Psychological Association, director of the Yale University Child Conduct Clinic, and author of over seven hundred peer-reviewed manuscripts and forty books, Dr. Alan Kazdin. Dr. Kazdin has noted that there are 32,647 combinations of symptoms that youth can have to meet the diagnosis of conduct disorder.
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To the extent that the symptoms of conduct disorder are independent of one another, this means there are over 32,000 different types of kids with conduct disorder. It is a clinical psychologist’s nightmare. There is no sensitivity or specificity to the diagnosis. It allows for a vast, diverse range of children to be diagnosed with the disorder. And it doesn’t predict anything. It’s essentially a hodgepodge of symptoms with very little utility.

Within secure juvenile correctional systems where I have conducted research, clinicians often don’t even bother doing the assessment for conduct disorder since nearly every youth meets criteria. Conduct disorder simply does not help differentiate children and youth in the criminal justice system. Thus, the diagnosis of conduct disorder suffers from many of the same criticisms as the adult antisocial personality disorder diagnosis (reviewed in
Chapter 2
).

But this picture is beginning to change. For the last twenty
years or so, a number of dedicated scientists have been developing measures to quantify callous and unemotional traits in youth. Psychologists believe that examining both the callous and unemotional traits and the antisocial and impulsive traits in youth will help to identify those at the highest risk for developing into full-blown adult psychopaths.

Trying to assess and predict which children will become psychopaths as adults is a difficult task. Some have argued that scientists should not even attempt such an endeavor because one side effect of diagnosing a child as a psychopath is the possibility the label might stigmatize the child. Such labeling could also lead to a self-fulfilling prophecy. Others have suggested that if parents are told their children are psychopathic, it may further the divide between parent and child. Finally, parents of children labeled psychopathic may be stigmatized as well. These are very serious concerns, and my colleagues who study these high-risk children are very sensitive to these issues. Indeed, scientists in the field generally go to great lengths to avoid the term
psychopathic
when discussing these youth. The term that is most commonly used is
callous and unemotional traits
. Among psychologists, youth with significant callous and unemotional (CU) traits and disruptive behaviors, or conduct disorder, are known as
CU/CD
, or callous conduct disordered youth.

It is clear from my own clinical experience, echoed by most other forensic practitioners who work with psychopaths, that nearly all psychopaths were emotionally abnormal as children. So if we want to help understand how the condition develops, and how to answer parents’ questions about how to help manage and treat these children, scientists have to try to understand how these emotional symptoms manifest themselves early in life. Indeed, ignoring the problem or not studying the problem is absolutely not the right answer. Careful and thoughtful science is the answer to helping to address psychiatric disorders, and psychopathy in particular.

As I discussed previously, researchers and clinicians who use the
DSM
are trained on how to assess and relate the symptoms in the manual to the clients in their care. Typically, a thorough assessment is done on a client based on an interview and a review of the client’s life history. It is from this information that trained experts then determine the psychiatric diagnosis according to the guidelines of the
DSM
. However, psychology uses a number of other techniques to quantify and assess psychiatric symptoms.

Given that psychology is the study of behavior, it is also then the study of the brain, since all behavior emanates from the brain. Psychologists have devised a number of techniques for measuring and quantifying behavior.

One method psychologists use to assess personality traits is to give a client a list of questions to answer. These so-called self-report inventories can be quite long. For example, the first version of the popular Minnesota Multiphasic Personality Inventory (MMPI) had 567 questions. Psychologists use the MMPI to assess the various dimensions of personality—like trustworthiness and introversion (the ability to feel comfortable in social settings). Instruments like the MMPI are useful to develop an understanding of the personality problems the psychologist’s client might be experiencing so that an appropriate treatment program can be developed. Self-report tests are common in psychology, and they have recently been developed to assess CU traits in youth.

The first and most commonly used self-report instrument to assess CU traits in youth is the Child Psychopathy Scale (CPS) developed by Dr. Don Lyman of Purdue University. The CPS includes questions asking the child how he (or she) relates to others, what types of things the child considers to be important, how angry the child gets, and so on.

Self-report inventories can be very helpful in assessing behavior, and they are very popular in psychology. However, self-report inventories have their critics and their limitations. Moreover, some of the limitations of self-report inventories are exacerbated when trying to assess CU traits in young children.

One rather obvious limitation of self-report instruments is that they require the ability to read. Despite dramatic decreases in the rate of illiteracy in the world, it is still a significant problem. And
illiteracy is much higher in children who have behavioral problems at school. Thus, many of the high-risk youth whom we want to assess for childhood CU traits may not be able to read and answer the questions on self-report scales like the CPS or the MMPI.
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Another limitation of self-report scales in psychology is that they require cooperation. An easy way to defeat a self-report test is to lie, randomly fill in the answers, or just flatly refuse to complete the test. This greatly limits the utility of self-report tests in adversarial contexts.

Finally, perhaps the most important limitation of self-report scales that attempt to assess CU traits is that children with such traits may lack the ability and insight to accurately report on their emotional world. Such a lack of insight may confound researchers’ attempts to assess these traits.

To address these issues, researchers have turned to other techniques to assess these traits in children. To complement children filling out questionnaires, researchers now often ask parents and other caregivers to complete questionnaires about their children as well. Of course, some of the same limitations apply to this strategy as they do to self-reports for children, but generally gathering more information is better when trying to assess CU traits.

With parent or caregiver self-reports, researchers try to get both parents to independently answer questions about the behavioral and emotional life of the child. If possible, additional self-report inventories are collected from teachers or other caregivers who have directly observed the child for a significant period of time.

Dr. Paul Frick of the University of New Orleans and collaborator Dr. Robert Hare of the University of British Columbia have developed a number of parent and teacher scales for the assessment of CU traits in youth, including the Antisocial Process Screening Device (APSD). The APSD is modeled and scored very similarly to the various versions of the Psychopathy Checklist.
⁷
The APSD is a twenty-item questionnaire that is given to parents or caregivers and a teacher. There is a self-report version for the youth to complete as well. A great deal of research has been conducted with the APSD; it has been used with youth ranging from four to eighteen years of age. In parallel, Dr. Frick developed the Inventory of Callous-Unemotional
Traits (ICU), with versions for parents, teachers, and the child to complete. The ICU has versions designed for preschool and elementary-school-age children; it was developed to address some potential technical limitations of the APSD scales.

When parents are asked about the emotional life of their child, one difficulty that arises is that it can be hard for parents to check off items indicating that their child lacks empathy, is violent, and appears to enjoy inflicting pain on animals. This is especially the case when their child might be involved in the legal system. Sometimes parents will fudge reports about the severity of their child’s misbehavior. Also, since people generally believe that a child’s misbehavior is partially the fault of the parents, parents may be further motivated to limit the reporting of their child’s problems. Indeed, as the letters I receive from parents with such children attest, it is a very difficult situation to deal with, and parents often just don’t know what to do.

The last kind of test that researchers use to assess CU traits in children (and adults) is an expert-rater device that explicitly assesses these traits, such as the Hare Psychopathy Checklist-Youth Version, which is an age-appropriate version of the adult Psychopathy Checklist.
⁸
Researchers interview the child, parent, and perhaps other key people in the child’s life, and then rate the child on CU traits. The limitations of such “expert-rater instruments” are that they take a lot of time to complete, are typically more expensive than self-report or parent and teacher reports, and require that the person doing the assessment is well trained. But one advantage of the Youth Psychopathy Checklist is that cooperation by the child, or the parents, is not necessary to complete the test. The Youth Psychopathy Checklist can be completed by reviewing details from teachers, coaches, neighbors, and other caregivers. In this way, it is possible, if necessary, to complete the assessment in the absence of talking to the child or parent, such as when a parole office needs to know how to develop a management or release plan for a young offender.

In my laboratory, my preference is to do all three types of reports on children who have elevated CU traits. We then compare the instruments to see if they generate the same pattern of results and to see if they identify the same children as scoring high or low.
The good news is that there have been considerable advances in the development of these assessment procedures in the last two decades; the bad news is that there is still a lot of work to be done. My lab’s data indicate that the various procedures for assessing CU traits in youth do not agree very well with one another. Youth who score high on self-report measures do not necessarily score high on expert-rated measures or parent ratings. We also found that the more severe the child scored on the expert-rated measures, the less likely we were to receive back reports from parents. The parents of children high in CU traits often did not return the test to the researchers. Sometimes the apple does not fall far from the tree.
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