High Risk?

By Richard Cross, Head of Practice Development Five Rivers Child Care Ltd

Severe Conduct Disorder (Juvenile Psychopathy). A model of early assessment and intervention

Edited Version First Published In Community Care Magazine,

Often one only needs to press the remote control switch of the television to on to find the media commenting on the devastation and harm, which has been caused by children. This harm is to individuals, animals and property and the comments are frequently around disbelief and confusion as to why the children of our society would do such a thing. This paper attempts to stimulate discussion on the need to implement a strategy of support and intervention for the children who are discussed so frequently in the media, who are responsible for a high percentage of the harm and offences committed within our society.

It also attempts to encourage reflection as too a move to a greater awareness of the factors which interplay in the development of high risk behaviour. As a reader you are encouraged to make sense of the behaviour presented by of the young people and to try and understand why at the start of their early life the scales were tipped away from a life with the qualities of love and trust to one of mistrust and hate.

Attachment: A Critical Time

When looking at this area, the concept of attachment can be beneficial in understanding the behaviour of the children, I am not advocating this element to the exclusion of other explanations but purely on the basis of where we may have an opportunity to do something and provide effective interventions.

I think it is appropriate to pose a question:

What Makes The Normal Process That Causes Attachment And Thus A Social Conscience To Occur To Be Short Circuited?

You just have to observe a new mother cuddling her baby, you can sense the attunment in the interactions, gazing into each other’s eyes in an effectional bond that joins them emotionally.

By understanding the development of a child in a nurturing and warm care environment, it provides an ability to understand the potential for experiences which are characterised as fragmented, neglectful and abusive to change the trajectory of a child in their life.

This crucial process which occurs in the first three years of life provides the child the formation of social attachments, but also a template for future emotional joining of others in meaningful and healthy relationships. I believe we all need a to have an ability to create an sense of understanding of a child’s behaviour and by being able to look back. at the early developmental cycle we can not only gain a sense of understanding but can give a point where informed interventions can be proposed.

Much is known about the biological and emotional effects of trauma upon the mind and the crucial importance of the primary caregiver in enabling the young child to develop the ability to be reflective and mentalize experience (Fonagy, 2002).

Therefore the failing of the attachment process brings difficulties in emotional awareness, perceiving and understanding the emotions of others and difficulties in regulating levels of arousal. This is why I firmly believe that the characteristics of those attempting to do meaningful work with such children need to be able to provide for these deficits by themselves being emotional aware and self aware of others.

I would therefore encourage interested professionals to explore the great deal that is now know about the possible effects on personality of physical, sexual and emotional abuse.

In my work with adults who would have scored high on the Revised Psychopathy Checklist – the PCL-R, although they are perceived as the most dangerous hard men. 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 and insight has assisted me in developing more appropriate interventions for children who have came from homes which have been described as war zones to assist in helping them understand themselves better and hopefully make better choices.

It provides a potential space where it is safe to think about the trauma, experience feelings about it and create the correct holding environment where healing can take place (Miller, 1993; Ward, 1998). This means that the adults responsible for the child’s care have a huge responsibility to be there to care for them, not just some of the time but all of time. In effect, the staff become part of the therapeutic parenting team.

In this way the milieu or life space in a group living environment becomes a focus for the staff to use daily events and processes as part of therapeutic work. The care staff can provide a responsive environment which manages the boundaries within which the child behaves.

This will ultimately assist the child to manage and regulate their internal affect. As we have seen, dissociation is utilised to protect the individual from overwhelming anxiety. Without realizing it, I fought to keep my two worlds separate. Without ever knowing why, I made sure, whenever possible, that nothing passed between the compartmentalization I had created between the day child and the night child (Marlyn Van Derbur (2004, p26)

An alternative reframing environment should be created by staff to help the child to alter their perception of the world and of self. In this way trust in the outside world becomes the foundation for self-trust and self-care as the child or young person grows and develops.

It is essential that staff strive to create a safe place in the real world so the child doesn’t need to retreat to their inner world. The C.A.R.E. approach embodies the notion proposed by Heard and Lake (1997) about supportive companionable. relating within a safe environment.

The importance of understanding the child’s behaviour a child who has been abused carries around a set of habitual expectations and responses specifically designed for survival. The child has developed mechanisms and behaviours to provide themselves with a sense of safety and control in situations where they had none. Staff continually strive to make sense of the child’s behaviour. This pattern is called a trauma bond (Herman, 1992; James, 1994).

Staff need to be supported do not take any of the behaviour personally (e.g. angry acting out). This can be particularly difficult when the child is violent, damages the carer’s property and attempts to test the messages provided by the adult. By reframing the child’s behaviours, one can see these as opportunities to undertake meaningful work and to question where the behaviour fits into an old pattern. In this way, staff arrive at a better understanding of why the child copes in a certain way.

By reframing, staff learn to view the behaviour as the child’s way of communicating, and are then able to use this understanding to help inform formal therapeutic interventions. If behaviour is seen as a type of communication, it may be asserted that some behaviours only occur if formal communication breaks down.

This can be a challenging concept, but by looking at violence as communication, for instance, it provides an opportunity for reflective practice that staff can harness to improve inter-relational understanding and outcomes for the child.

For staff to be able to make sense of the extreme transference and chaos within the child’s inner world, they must remain grounded and self-aware. In doing so they are able to react calmly and non-punitively in the face of a child’s anger and anxiety. Support structures are utilised by all staff (e.g. supervision and team meetings) where the focus is on processing, and ensuring understanding of, dynamics, feelings, and how best to meet the child’s needs (Tomlinson, 2004).

Assessment

From the onset, assessment must be accurate, to explore other explanations for the behaviour and co-presenting conditions e.g. PTSD, Dissociative disorders, ADHD, early signs of personality disorder – BPD, etc.

The definition of Severe Conduct Disorder can be described as a marked life-long attitude of being self-centered, taking what one wants when one wants it without any regard for the feelings and rights of others. It is a DSM-IV diagnosis, which has various symptoms (15) that fall into 4 sets:

1. Aggression to people and animals
2. Destruction of property
3. Deceitfulness or theft
4. Serious violation of rules

Of these 15 symptoms, at least 3 have to have occurred in the past 12 months. Prevalence is said to be approximately 8% of boys and 3% of girls (Offord, 1991), although the ratio during early childhood of boys to girls is 3:1 by adolescence this disparity is viewed as abating rapidly.

It was emphasised that juveniles with SCD can in the latter stages of childhood commit many of the severe crimes seen in society which cause significant harm to others e.g. forced sex, physical cruelty, use of weapon. 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 ultimately mean that they distance themselves from a broad based peer group and can set the stage for involvement with deviant peers (Lochman, 2001).

This can mean these young people begin to isolate themselves from pro-social peers and this environmental shift can predict delinquency, school dropout, internalising problems, adolescent pregnancy and drug and alcohol use.

A particular group of rejected children who over-estimate their social acceptance may be at particular risk for aggression. Aggression during early toddler years is common and the peak frequency for inflicting physical aggression upon others is at the age of two – which may be surprising to some (Tremblay, 1996).

Aggression is therefore common during the early stages of development and most children use some form of physical aggression, for instance at 18 months of age, 60% of boys and 30% of girls hit their peers. However, the frequency of this aggression steadily decreases from the age of 2 to 12years, but despite this gradual decline of aggressive behaviour over time a group of 5 – 10% of children (SCD) continue with serious levels of aggressive behaviour (Frick, 1998).

The most common co-occurring problems for youth with Conduct Disorder (CD) are substance abuse, ADHD, and depression. ADHD has been found in clinical samples diagnosed with CD to present with rates of 65% – 90% (Abikoff, 1992). When present with CD youth have more CD symptoms, early onset of SCD, more violent behaviour and early and greater substance abuse. It is often associated with alcohol and drug use and is this also resistant to treatment. Depression occurs in 15% – 31% of CD youth (Zoccolillo, 1992), which may be exasperated due to interpersonal conflicts with peers and family. Despite this it does not appear to alter the course of CD.

It is this sub group of chronic aggressive children are viewed as being of greatest risk of displaying the most physical violence, delinquency, substance abuse and having school difficulties during adolescence (Nagin, 1999).

The adult equivalent of this disorder is severe anti-social personality disorder. This sub group of adult offenders have psychopathic traits (egocentricity, shallow emotions and an absence of empathy, anxiety and guilty). However, it is still not clear if Psychopathy can be reliably assessed in the youth population, but a subgroup of conduct disorder youth exhibit callous unemotional (CU) traits.

The anti-social screening device (APSD), which has been adapted from Hare’s Psychopathy Checklist – revised has been used with adolescents to assess CU traits.

The features of Severe conduct disorder are:

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

Detection of Conduct disorder therefore needs to assess core symptoms and behaviour in relation to age and attempt to gain information from a multiple of sources e.g. parent, teacher, and self-report. These assessments should use structured interviews with parents and youth (Diagnostic Interview Schedule for Children), but can also use behavioural checklists (Behavioural Assessment Scale for children) with age-based norms can be useful.

Word Of Caution

The assessment material presented above aims to assist clinicians and therapists to indentify and therefore provide support and the most appropriate interventions to children and young people. These indicators do not provide the relational insight into the origins of the individual child’s behaviours.

We must therefore understand what the trauma has done to a child during development and therefore to the adults they will become.

I always remind myself that parental rejection to the child produces children who feel untouchable, repellent or contaminated (Hopkins, 1991, p 197).

Therapeutic Risk Factors

The emphasis is on the presence and interplay of both social and biological risk factors in the increasing of the rates for anti-social and violent behaviour.

Identifiable risk factors for Childhood onset of conduct disorder are:

• Parental antisocial behaviour
• Parental substance abuse
• Younger maternal age (what age they had first birth, this would continue onto latter births as a risk factor)
• Low IQ (Silverthorn,1999)
• Sexual abuse
• Early menstrual onset (Moffit et al, 2001)
• Limited or lax parental supervision
• Harsh discipline (and abuse)
• Social risk factors
• Low social economic status (SES)
• Lower maternal education
• Does not vary by race when SES and neighbourhood characteristics are controlled

Overall findings are that risk factors are similar for both genders, but being male is a risk factor in itself and in girls the risk factors also include running away from home (McLaren, 2000) and Child abuse (Leve, in press).

Treatment (Chasidim, 2000; Lesley, 1992; Waslick 1999)

“I’m afraid we won’t be able to do much about prison reform until we start getting a better grade of prisoner” Lester Maddox, during his tenure as the Governor of Georgia

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

There is at present no simple or sure fire fix to the problem of SCD and most interventions need to be in place for months or even years.

Above all there needs to be intervention and whether in family or if child is looked after there is opportunity to make a difference in creating an experience which will assist in gradually changing the internal working model of the child.

Some practical interventions carer can begin with are:

• Treat comorbid substance abuse first.
• Structure children’s activities and implement consistent behaviour guidelines.

Emphasize parental monitoring of children’s activities (where they are, who they are with), encourage the enforcement of curfews and boundaries/containing structures.

Discuss and demonstrate clear and specific parental communication techniques.

Help caregivers establish appropriate rewards for desirable behaviour.

Help establish daily routine of child-directed play activity with parent(s).

Treatments that don’t work and viewed as not meriting government funding are:

• Shock treatments
• Peer counselling
• Excellent delivery of “ordinary” social services (APA. 1997)
• Boot camps

Treatments that do work (at least some positive treatment outcome) tend to be

• Behavioural
• Skills oriented (moral reasoning, problem solving, anger management)
• Multi model
• Programmes with family based components e.g. parent training, family therapy, couples therapy (opportunity for the excellent delivery of therapeutic residential child care services to provide attuned care required)
• Treatment of parent child interactions
• Multi-systemic therapy (MST)

Some promising research is also starting to provide an insight into detectable behaviours that can be identified that may indicate the possible presence of SCD. These have been termed as possible gateways and therefore treatment can be directed towards the following area’s fire setters, graffiti, sexual offenders, sexually abused, and theft.

The use of medication is understudied but it is generally targeted towards the management of reactive aggression, explosive temper, hostility / negative mood, co morbidity and ADHD. Stimulants (amphetamine, methylphenidate or Ritalin) are seen to help manage ADHD and might also reduce aggression.

In conclusion there is a wide range of initiatives for addressing the problems which have began to provide promising results and demonstrate efficancy at targeting needs from pre-school years into adulthood.

It must be kept in focus when it comes to allocating resources, that early conduct disorder problems have long lasting effects that can impact on us all in terms of crime, mental health, driving, sexual outcomes, education and employment. With the possible exception of IQ, no other factor that can be present during childhood has as far reaching consequences in terms of development.

Recommendations:

1. Identify the most at risk children preferably before they start school
2. Trial interventions through the wider use of validated intervention programmes (“don.t put all your eggs in the one basket”).
3. Target 1 – 5 % of very young children
4. Interventions with those assessed as highest risk, needs to be intensive and sustained
5. Co-existent psychiatric disorders must be treated
6. Programmes need to be developed for females based on evidence based protocols as opposed to placing them on programmes developed for males e.g. do better on one-to-one placements where they are isolated from the anti-social peers.
7. Education system needs to provide a safe and controlled stimulating learning environment for the pupils (inclusion not exclusion where at all possible)

If you let young people trash their lives, they will trash your society

Peter Garrett, singer with Midnight Oil

By Richard Cross

Richard is currently working for Five Rivers Child Care Limited as Head of Practice Development.

He is a UKCP registered psychotherapist who has also worked with high risk adolescents for many years and was the co-author of a therapeutic programme Invitations to change. (Focus EQUIP) for the New Zealand Corrections Department, which is used with high risk adolescent offenders.

e-mail: Richard.cross@five-rivers.org

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