Born under a bad sign? (child psych/forensics question)

[Ceke2002]

From a clinical point of view, do you think some children can just be born bad? The old nature vs nurture argument I know, but I was reminded of this subject the other day and it got me thinking about one case in particular (a younger child who grew up in my birth neighbourhood).

Case in question: Male child, adopted, both parents still together up until middle childhood years (mother passed away), raised in a loving, stable, extended family environment. Child showed little to no emotional response or awareness as an infant (I've never seen a baby that was able to fix such a cold stare on someone, before or since, genuinely disturbing to witness); early signs of violent tendencies and lack of empathy by the time he was a toddler (regularly attacked his mother with enough force, even for a child of that age, to leave bruises - would then sit by his mother and hit or press those same bruises, showed a rather unnerving delight when he elicited a pain response expression from her); never made it past second grade primary school due to an almost total inability to accept authority of any kind; middle childhood through to pre-teen years began extending his violent streak towards children smaller than him, attempted to stab his mother several times (he was around 5-6 at the time, she was undergoing treatment for aggressive breast cancer, which she eventually died of - this is the only environmental stressor I'm aware of); eventually began engaging in acts of arson and animal cruelty (he bashed the family dog's head in with a brick, for example). His adoptive father (and mother when she was still alive) bent over backwards trying to help him with therapy, and numerous consultations with psychiatrists and paediatric specialists (he was eventually removed from the family home in his middle teen years after he attempted to burn the house down while his father and adopted brother were still asleep inside). Since that time he has been in and out of juvenile detention and jail for various offences ranging from armed robbery, to grievous bodily harm, kidnapping, and rape.

So obviously I'm thinking 'Okay, pretty clear cut case of psychopathy' (I could be wrong of course), but then if psychopathy is nature not nurture what do you do with these sorts of children? I'm assuming cases like this are rare, but how do you deal with a child like this, whose almost every action points towards them eventually becoming a potential danger to society? From a forensic of child psych point of view is there anything you can do at all, or is it a case of the child's lot already being cast and you just try your best to minimise the fallout (so to speak?)

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[nitemagi]

It's a good question of if there's real evidence on what can divert problems of psychopathy in children. I haven't followed up on the source but I remember a statistic of only 50% of children with conduct disorder go on to develop ASPD. Not that ASPD really encapsulates psychopathy in the first place.

I tend to take 3 views on this --
1. This is just a biological variant, like any other mutation. This exists in society as an "intraspecies predator" for the purpose of our long history of tribal warfare. They're beneficial to hunting other humans for the safety of their tribe. The difficulty is that we don't have an easy avenue for that aside from being a soldier, and don't have a containment mechanism for them when they're not in that role.
2. There's something here developmentally that we can divert. As in if we can train them in some empathy, to practice taking another POV it'll help. The DSPD experiment in the UK and its predecessor seems to show that at least part of this is treatable under extreme containment.
3. There's some other, bigger picture, thing to understand here. More of a spiritual/religious view of the whole thing, which offers neither specificity or clear solutions (though I do have ideas that I choose not to post here).

 

[Ceke2002]

It's a good question of if there's real evidence on what can divert problems of psychopathy in children. I haven't followed up on the source but I remember a statistic of only 50% of children with conduct disorder go on to develop ASPD. Not that ASPD really encapsulates psychopathy in the first place.

I tend to take 3 views on this --
1. This is just a biological variant, like any other mutation. This exists in society as an "intraspecies predator" for the purpose of our long history of tribal warfare. They're beneficial to hunting other humans for the safety of their tribe. The difficulty is that we don't have an easy avenue for that aside from being a soldier, and don't have a containment mechanism for them when they're not in that role.
2. There's something here developmentally that we can divert. As in if we can train them in some empathy, to practice taking another POV it'll help. The DSPD experiment in the UK and its predecessor seems to show that at least part of this is treatable under extreme containment.
3. There's some other, bigger picture, thing to understand here. More of a spiritual/religious view of the whole thing, which offers neither specificity or clear solutions (though I do have ideas that I choose not to post here).

Thank you. In the case example I used I think I'd probably lean more towards agreeing with your first point about biological variance, but then again you can't exactly lock a child up for what they might do in the future (obviously). I definitely see your point abut being about to potentially attempt to divert them from a developmental point of view as well, although in this particular case I really don't know if it would've been possible to have helped this child develop any traits of empathy - I do remember there was a brief period where he was doing somewhat better when he discovered a love of engines and started an apprenticeship as a mechanic (it was the only time I know of that he willingly accepted any form of authority, but unfortunately it didn't last very long seeing as it's not generally a good idea to tell your boss to get effed and start attacking your fellow workers if you actually want to keep your job).

 

[Ceke2002]

I do feel sorry for parents in cases like this as well. The default societal judgement does seem to be if a child is bad it must be something the parent's have done wrong. I do remember the father in my example copping a lot of flack when he had his son forcibly removed from the family home, and changed the locks - like he deserved to be judged because he abandoned his child. I know the family as a whole never stopped trying to love this child, but there has to be a point where your own safety and the safety of other family members must take precedence (and having your teenage son taken out of the home because he's basically just tried to burn you to death in your sleep isn't abandoning your responsibility as a parent, it's basic instincts of survival and protection of the family unit as a whole kicking in as far as I'm concerned). I really don't think his parents, including his Mum when she was still alive, could have done any more to try and help him if they tried.

 

[nitemagi]

It's hard to know. The presumption is that either "soft" parenting (love) or "hard" parenting (punishment/rules/structure) are what's missing. I really don't know if that's the case at all. In some ways I think about leverage being important to pressure someone to try ways to change. In the european experiments, the only thing that seemed to help was hospitalization without hope of release until the psychiatrist agreed they were ready -- which may have led to them actively participating in treatment. It's a little Clockwork Orange-ish though, but in these pilot programs (that I heard about at a conference) they reduced recidivism to like 8% (from 80+%).

Simply loving a child doesn't do the same thing.

 

[Ceke2002]

It's hard to know. The presumption is that either "soft" parenting (love) or "hard" parenting (punishment/rules/structure) are what's missing. I really don't know if that's the case at all. In some ways I think about leverage being important to pressure someone to try ways to change. In the european experiments, the only thing that seemed to help was hospitalization without hope of release until the psychiatrist agreed they were ready -- which may have led to them actively participating in treatment. It's a little Clockwork Orange-ish though, but in these pilot programs (that I heard about at a conference) they reduced recidivism to like 8% (from 80+%).

Simply loving a child doesn't do the same thing.

Agreed, providing parental love and support is one thing, but you can't love a child better. Not sure what sort of treatment options were available for a child with ASPD or 'psychopathy' at the time, but I can imagine resources were somewhat limited seeing as we're talking about the late 70's and 80's for the most part. Like I said I know they tried therapy and psychiatric assessments/appointments numerous times, but what in the way of treatment any of that entailed I don't know. I think the only other option for them was to have him made a ward of the state and placed into care, which I know his mother was vehemently opposed to considering he would've most likely ended up in a group home (many of which came under historical scrutiny during a Royal Commission into instituitonal child abuse in South Australia - so, yeah, can't have seen it doing him much good in hindsight anyway).

 

[Crayola227]

i thought maybe this thread would discuss what evidence there is around time of year born and personality, etc

apparently there's *some* evidence for this

if I get bored I'll look some up if no one else does

 

[Doctor Bagel]

I treated a couple who had adopted a child who very clearly had antisocial personality disorder and had essentially tormented them throughout his whole life. They had some struggles with setting boundaries but were otherwise loving, well-intentioned parents who actively sought out treatment for this kid throughout his childhood. I'm sure there were things they could have done differently, but regardless, it wasn't their fault, and this kid wasn't the way he was because of trauma or neglect.

 

[lymphocyte]

It's a good question of if there's real evidence on what can divert problems of psychopathy in children. I haven't followed up on the source but I remember a statistic of only 50% of children with conduct disorder go on to develop ASPD. Not that ASPD really encapsulates psychopathy in the first place.

I tend to take 3 views on this --
1. This is just a biological variant, like any other mutation. This exists in society as an "intraspecies predator" for the purpose of our long history of tribal warfare. They're beneficial to hunting other humans for the safety of their tribe. The difficulty is that we don't have an easy avenue for that aside from being a soldier, and don't have a containment mechanism for them when they're not in that role.

This is a pretty interesting thread @Ceke2002. I've never really thought about "psychopathy" carefully before. It certainly seems laden with forensic implications that detract from a purely psychiatric/psychological conceptualisation. But what are we talking about if we remove the forensic context? What about the social context? What does it mean to be a lonely psychopath, with nobody to manipulate or be mean to? Is there even such a thing?

I looked up some of the neurology literature on the loss of "empathy" post CVA or trauma. From a neurological point of view, empathy is a loose term that entails lots of different skills, abilities, and dispositions, like prosody, mentalising, perspective taking, etc. These all exist on an affective and cognitive level, and "psychopathy" seems to originate, in part, from a disconnection between the affective and cognitive components of empathy. This disconnection seems baffling, because psychopaths still possess, in part, the skills, abilities, and dispositions for both though the two just don't hook together. It's also probably an area where developmental considerations might play a larger explanatory role or serve as a therapeutic target... Anyways, the neurology literature on empathy is pretty neat. Lots to read.

Hillis AE. Inability to empathize: brain lesions that disrupt sharing and understanding another's emotions. Brain : a journal of neurology. 137(Pt 4):981-97. 2014.

Shamay-Tsoory SG. The neural bases for empathy. The Neuroscientist : a review journal bringing neurobiology, neurology and psychiatry. 17(1):18-24. 2011.

Leigh R, Oishi K, Hsu J. Acute lesions that impair affective empathy. Brain : a journal of neurology. 136(Pt 8):2539-49. 2013.

 

[lymphocyte]

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[Ceke2002]

This is a pretty interesting thread @Ceke2002. I've never really thought about "psychopathy" carefully before. It certainly seems laden with forensic implications that detract from a purely psychiatric/psychological conceptualisation. But what are we talking about if we remove the forensic context? What about the social context? What does it mean to be a lonely psychopath, with nobody to manipulate or be mean to? Is there even such a thing?

I looked up some of the neurology literature on the loss of "empathy" post CVA or trauma. From a neurological point of view, empathy is a loose term that entails lots of different skills, abilities, and dispositions, like prosody, mentalising, perspective taking, etc. These all exist on an affective and cognitive level, and "psychopathy" seems to originate, in part, from a disconnection between the affective and cognitive components of empathy. This disconnection seems baffling (because psychopaths still possess, in part, the skills, abilities, and dispositions for both though the two just don't hook together). It's also probably an area where developmental considerations might play a larger explanatory role or serve as a therapeutic target...

The only other psychopath, or person with psychopathic tendencies at least, that I've come into contact with is the Psychiatrist I was seeing before my current one. Not sure if he'd meet the diagnostic criteria for APSD, but if you ask other Psychiatrists of his same generation what their thoughts are about him, the general consensus is 'charming psychopath, who ruined the lives of far too many patients'. His was a different breed of psychopathy though. The child, well now a grown man, in the original case I mentioned did eventually at least try to emulate some range of normal emotional response, especially if he knew by doing so he could manipulate someone or gain power over them for his own needs, but he never quite managed to get it right - you could see what he was trying to do, but his emotional responses never really rang true (there was always something very cold and disconnected about them, like watching someone putting on a mask). In contrast the Psychiatrist I was seeing was very good at initially seeming to present an emotional range that would be considered, I suppose the word would be 'normal', and it was only after some time that you began to realise how much of an act it was and how shallow and glib those emotional displays really were (and just how much he was manipulating and toying with his patients for his own messed up gratification). He was basically a very charming, and dangerous performer with the ability to change emotional expression as easily as discarding one item of clothing and putting on another. I actually consider him to be far scarier, and potentially more dangerous, than the original case I presented, because with the former you only had to spend a short amount of time with this child/person to know something wasn't right (even when he was trying to emulate emotional expressions such as sadness, contrition, joy, love, etc there was something really off about it) - whereas in contrast you didn't really see the other person coming until it was too late because they had that ability to disarm you (if that makes sense).

It does make me wonder if this means there are varying degrees of psychopathy from a neurological point of view, like are some psychopaths brains less functional or more 'miswired' than others.

 

[Doctor Bagel]

The only other psychopath, or person with psychopathic tendencies at least, that I've come into contact with is the Psychiatrist I was seeing before my current one. Not sure if he'd meet the diagnostic criteria for APSD, but if you ask other Psychiatrists of his same generation what their thoughts are about him, the general consensus is 'charming psychopath, who ruined the lives of far too many patients'. His was a different breed of psychopathy though. The child, well now a grown man, in the original case I mentioned did eventually at least try to emulate some range of normal emotional response, especially if he knew by doing so he could manipulate someone or gain power over them for his own needs, but he never quite managed to get it right - you could see what he was trying to do, but his emotional responses never really rang true (there was always something very cold and disconnected about them, like watching someone putting on a mask). In contrast the Psychiatrist I was seeing was very good at initially seeming to present an emotional range that would be considered, I suppose the word would be 'normal', and it was only after some time that you began to realise how much of an act it was and how shallow and glib those emotional displays really were (and just how much he was manipulating and toying with his patients for his own messed up gratification). He was basically a very charming, and dangerous performer with the ability to change emotional expression as easily as discarding one item of clothing and putting on another. I actually consider him to be far scarier, and potentially more dangerous, than the original case I presented, because with the former you only had to spend a short amount of time with this child/person to know something wasn't right (even when he was trying to emulate emotional expressions such as sadness, contrition, joy, love, etc there was something really off about it) - whereas in contrast you didn't really see the other person coming until it was too late because they had that ability to disarm you (if that makes sense).

It does make me wonder if this means there are varying degrees of psychopathy from a neurological point of view, like are some psychopaths brains less functional or more 'miswired' than others.

What did he do to hurt patients? I know there are psychopath doctors and other psychopaths in the mental health field, but it's such a scary thought.

 

[Beatrice363]

From a clinical point of view, do you think some children can just be born bad? The old nature vs nurture argument I know, but I was reminded of this subject the other day and it got me thinking about one case in particular (a younger child who grew up in my birth neighbourhood).

Case in question: Male child, adopted, both parents still together up until middle childhood years (mother passed away), raised in a loving, stable, extended family environment. Child showed little to no emotional response or awareness as an infant (I've never seen a baby that was able to fix such a cold stare on someone, before or since, genuinely disturbing to witness); early signs of violent tendencies and lack of empathy by the time he was a toddler (regularly attacked his mother with enough force, even for a child of that age, to leave bruises - would then sit by his mother and hit or press those same bruises, showed a rather unnerving delight when he elicited a pain response expression from her); never made it past second grade primary school due to an almost total inability to accept authority of any kind; middle childhood through to pre-teen years began extending his violent streak towards children smaller than him, attempted to stab his mother several times (he was around 5-6 at the time, she was undergoing treatment for aggressive breast cancer, which she eventually died of - this is the only environmental stressor I'm aware of); eventually began engaging in acts of arson and animal cruelty (he bashed the family dog's head in with a brick, for example). His adoptive father (and mother when she was still alive) bent over backwards trying to help him with therapy, and numerous consultations with psychiatrists and paediatric specialists (he was eventually removed from the family home in his middle teen years after he attempted to burn the house down while his father and adopted brother were still asleep inside). Since that time he has been in and out of juvenile detention and jail for various offences ranging from armed robbery, to grievous bodily harm, kidnapping, and rape.

So obviously I'm thinking 'Okay, pretty clear cut case of psychopathy' (I could be wrong of course), but then if psychopathy is nature not nurture what do you do with these sorts of children? I'm assuming cases like this are rare, but how do you deal with a child like this, whose almost every action points towards them eventually becoming a potential danger to society? From a forensic of child psych point of view is there anything you can do at all, or is it a case of the child's lot already being cast and you just try your best to minimise the fallout (so to speak?)

I really feel that your child has psychotic disorder. Psychosis is usually a sign or symptom of a serious problem, including some serious medical problems. A proper and thorough assessment will allow the accurate diagnosis of such a disorder in children. One of my friend's child had faced the same situation and the cognitive behavioural therapy from a clinic at North York had been an effective treatment for his psychosis.

 

[splik]

Well historically, the implicit difference between sociopathy and psychopathy was that sociopaths were made and psychopaths were born. We dont use the term sociopathy in the medical and psychological literature anymore however, though it is used in the anthropological literature and has a different meaning altogether. Psychopathy is not the same as antisocial personality disorder, though it is classified as a subtype in the DSM alternative formulation for personality disorder. Antisocial personality disorder is actually a rather fraught diagnosis (especially given that it contradicts the DSM definition of mental disorder, uses circular logic, and none of the criteria are personality-based) compared with psychopathy, which has the strongest support as a construct of any of the personality disorders in the DSM - though this isn't saying much.

I believe that psychopathy is strongly biological and that psychopaths are born but it does not necessarily follow that psychosocial interventions in childhood could not help or that these kids are destined to be monsters. This kind of fatalistic thinking is unhelpful, it's not helpful to stigmatize and label children and create a self-fulfilling prophecy. Antisocial personality disorder and conduct disorder have strong psychosocial roots however- they are associated with deprivation, criminal families, poor supervision, disruptive families, large family size. The evidence for abuse playing a major role is much weaker.

Though I tend to think the role of biology is overplayed in psychiatry, when it comes to psychopathy I don't think enough is made of it. The discussion has significant ethical implications of course, especially if you are looking at biomarkers that might predict the development of it, or risk of violence recidivism. (I'm going to be talking about this latter area in a neurolaw course at the AAPL meeting this year).

Here are some readings on the neurobiology of psychopathy:
The antisocial brain: psychopathy matters
Successful and Unsuccessful psychopaths: a neurobiological model
The Neurobiology of Psychopathy
Neurobiological Basis of psychopathy

And here is a nice chapter on family influences on delinquency (David Farrington has probably done more in this area than anyone)

 

[splik]

I treated a couple who had adopted a child who very clearly had antisocial personality disorder and had essentially tormented them throughout his whole life. They had some struggles with setting boundaries but were otherwise loving, well-intentioned parents who actively sought out treatment for this kid throughout his childhood. I'm sure there were things they could have done differently, but regardless, it wasn't their fault, and this kid wasn't the way he was because of trauma or neglect.

but how old was the kid when he was adopted. I've treated some extremely disturbed kids who did horrific things and were adopted. The parents in one particular case were fine (well they were mormon but apart from that they were clearly very loving) but usually in these sorts of cases the damage happens in the first few months of life. From a psychoanalytic perspective, we'd be thinking of a very early developmental arrest, in the first few months of life. Interestingly, they are looking at using mentalisation-based treatment for antisocial personality. See here

 

[Jules A]

but how old was the kid when he was adopted. I've treated some extremely disturbed kids who did horrific things and were adopted. The parents in one particular case were fine (well they were mormon but apart from that they were clearly very loving) but usually in these sorts of cases the damage happens in the first few months of life. From a psychoanalytic perspective, we'd be thinking of a very early developmental arrest, in the first few months of life. Interestingly, they are looking at using mentalisation-based treatment for antisocial personality. See here

I have cared for more than a few adopted as infants often taken right from the hospital without evidence of neglect/abuse who like others have written had what held up to be loving adoptive parents and a safe home but none the less presented with a variety of difficulties. This makes me suspect in-utero exposure to drugs or etoh and likely poor maternal care in addition to familial predispositions. It seems there are many well meaning but naive people who think hugs, a lake home and pony rides can ameliorate the biological predisposition and/or environmental damage that has been done.

 

[Ceke2002]

What did he do to hurt patients? I know there are psychopath doctors and other psychopaths in the mental health field, but it's such a scary thought.

He basically groomed patients through psychological manipulation in order to eventually begin a sexual relationship with them. To this end he breached confidentiality, encouraged patients to cut ties with friends and family, and fostered an environment of fear, learned helplessness and dependence on him. He also molested and raped patients while they were under twilight sedation undergoing rapid naltrexone detox (some he fondled their breasts and performed digital penetration, others he had intercourse with), he was observed doing this a number of times; however the people he had 'employed' to 'work' in his illegal non registered inpatient clinic were also patients that he had handpicked for both their devotion to him and their lower education status - this way he could use the excuse that the patient he was molesting was a survivor of child sex abuse (many of them were, along with other forms of childhood abuse/trauma) and that they had consented prior to having a breast and pelvic 'exam' performed while they were out cold so as to reduce their level of stress (he knew the patients who 'worked' at the clinic wouldn't think to question him, and as far as I know he was never observed having full sex with any patient under sedation so he got away with it).

Apart from pyschological manipulation, grooming, sexual boundary violations, molestation and rape, he really enjoyed placing patients under what he called a 'controlled state of pain or discomfort' with the explanation that it would help break down a patient's resistance and be advantageous for therapy - most of the time he would do this by injecting an opiate dependent patient with a high enough dosage of naltrexone in order to induce a sudden and severe withdrawal (and he derived obvious enjoyment from it) I've recently found out this was his modus operandus at a former clinic he was employed at as well, and his behaviour so disturbed other members of staff that he was eventually fired and banned from entering clinic premises.

(edited to remove discussion of personal history).

 

[Ceke2002]

Well historically, the implicit difference between sociopathy and psychopathy was that sociopaths were made and psychopaths were born. We dont use the term sociopathy in the medical and psychological literature anymore however, though it is used in the anthropological literature and has a different meaning altogether. Psychopathy is not the same as antisocial personality disorder, though it is classified as a subtype in the DSM alternative formulation for personality disorder. Antisocial personality disorder is actually a rather fraught diagnosis (especially given that it contradicts the DSM definition of mental disorder, uses circular logic, and none of the criteria are personality-based) compared with psychopathy, which has the strongest support as a construct of any of the personality disorders in the DSM - though this isn't saying much.

I believe that psychopathy is strongly biological and that psychopaths are born but it does not necessarily follow that psychosocial interventions in childhood could not help or that these kids are destined to be monsters. This kind of fatalistic thinking is unhelpful, it's not helpful to stigmatize and label children and create a self-fulfilling prophecy. Antisocial personality disorder and conduct disorder have strong psychosocial roots however- they are associated with deprivation, criminal families, poor supervision, disruptive families, large family size. The evidence for abuse playing a major role is much weaker.

Though I tend to think the role of biology is overplayed in psychiatry, when it comes to psychopathy I don't think enough is made of it. The discussion has significant ethical implications of course, especially if you are looking at biomarkers that might predict the development of it, or risk of violence recidivism. (I'm going to be talking about this latter area in a neurolaw course at the AAPL meeting this year).

Here are some readings on the neurobiology of psychopathy:
The antisocial brain: psychopathy matters
Successful and Unsuccessful psychopaths: a neurobiological model
The Neurobiology of Psychopathy
Neurobiological Basis of psychopathy

And here is a nice chapter on family influences on delinquency (David Farrington has probably done more in this area than anyone)

Thank you for this great response and further reading material. I do sometimes get psychopathy and ASPD (sociopathy?) mixed up, because many of the articles I have read on the subject seem to use the terms interchangeably, or spend time arguing about whether psychopathy is a subtype or a separate condition. It does get confusing knowing which terminology is correct to use.

I do wonder if this child's life course may have turned out differently if he had been given the correct psychosocial interventions or treatment, or if someone had been able to effectively engage him in treatment in the first place. His mother was very close friends with mine, I saw her completely breakdown from sheer stress and exhaustion a number of times. My Mum's advice to her was always 'have him put away', and she would refer to the child in terms of being a 'bad seed', which I always thought wasn't exactly helpful.

 

[Doctor Bagel]

but how old was the kid when he was adopted. I've treated some extremely disturbed kids who did horrific things and were adopted. The parents in one particular case were fine (well they were mormon but apart from that they were clearly very loving) but usually in these sorts of cases the damage happens in the first few months of life. From a psychoanalytic perspective, we'd be thinking of a very early developmental arrest, in the first few months of life. Interestingly, they are looking at using mentalisation-based treatment for antisocial personality. See here

Interestingly they gained custody of this kid the day he was born, so no early infancy environmental explanation.

 

[Merovinge]

Interestingly they gained custody of this kid the day he was born, so no early infancy environmental explanation.

I'd wager epigenetic effects from in utero are the most likely explanation, although I suppose some people are simply calling this "genetic" influence. As Splik has noted, it's a very biologic phenomenon, but I would guess an epigenetic transmission would make more sense given the association of sociopathy with ACEs and the like.