Psychopathy and young offenders

Adolescents

Psychopathy and young offenders

The PCL:YV includes the 20 PCL-R items but with definitions and scoring criteria adjusted to provide developmentally appropriate measures of the key traits for adolescents between the ages of 13 and 18 years.4 Each item is scored on a three-point scale (2, item applies; 1, applies to a certain extent; 0, does not apply). The maximum score is 40. No explicit cut-off score is recommended in the manual; the relevance of scores is considered according to which percentile they belong. The PCL:YV requires a comprehensive data set (e.g. file reviews, client interviews, ­ collateral interviews) and a trained rater makes the decision regarding the extent to which any given symptom is present. The APSD is a 20-item rating scale developed to measure developmental equivalents of the PCL-R items in children aged between 6 and 13 years.5 The assessment format of the APSD differs from the PCL-R and PCL:YV. The APSD is completed by untrained raters; parallel versions exist for parents, teachers and self-report. Each item is scored on a three-point scale (0, not at all true; 1, sometimes true; 2, definitely true). The total score possible is 40, and various cut-off scores have been utilized in the research. An overview of the items included in the PCL-R, PCL:YV and APSD is provided in Table 1. Extending the construct of psychopathy downward to adolescents and children has been justified on several counts. It might facilitate early identification, prevention and clinical intervention, including psycholegal decisions regarding disposal, placement, monitoring and supervision and so on.6 Based on current evidence this is more hope than reality: there is no compelling evidence for the reliable identification of which individuals will show stability from childhood through to adulthood. Furthermore, concerns have been expressed about the utility of this construct as it applies to children and adolescents.6,7 Within the constraints of this contribution it is impossible to provide an exhaustive discussion of all the relevant issues, however the intention here is to provide an overview of the main findings. For psychopathy to be a meaningful construct in children and adolescents, a first step on the long road to validation would be to demonstrate convergence of findings with the adult literature. We consider the main findings from this literature below.

Lorraine Johnstone David J Cooke

Abstract There is growing interest in the construct of psychopathy in both adolescent and childhood populations. This interest is underpinned by observations that psychopathy in adults is linked to chronic criminal behaviour, institutional disruptiveness, unresponsiveness to treatment and comorbidity with other disorders. Extending this construct to young people is fraught with difficulty both conceptually and practically. In this contribution we review the extant literature and conclude that the use of the psychopathy construct in young people is currently more prejudicial than probative; the lacunae in the empirical base means that decisions about the individual case – based on this construct – can only be speculative.

Keywords Antisocial Process Screening Device; callous unemotional traits; psychopathy; Psychopathy Checklist Youth Version

Psychopathic personality disorder (PPD) refers to a syndrome characterized by specific traits which traverse the emotional, interpersonal and behavioural domains. Emotionally, those with PPD are lacking in affection, attachment, empathy and remorse. Interpersonally, they exude a superficial charm and grandiose sense of self; they are pathologically dominant and actively deceive others by engaging in pathological lying; and they are conning and manipulative. Behaviourally, they are impulsive and irresponsible; they lack planfullness.1 The 20 item Psychopathy Checklist Revised (PCL-R)2,3 is the most widely used measure of this disorder in adults. Instruments purporting to assess similar characteristics in children and adolescents are gaining prominence. Two have been explicitly derived from the PCL-R: the Hare Psychopathy Checklist Youth Version (PCL:YV)4 and the Antisocial Processes Screening Device (APSD).5

Psychopathy in adults Psychometric work has confirmed that psychopathy is a hierarchical structure in which the superordinate trait, psychopathy, overarches three highly correlated symptom facets: • arrogant and deceitful interpersonal style • deficient affective experience • an impulsive and irresponsible behavioural style. (The structure of the PCL-R has been the subject of some debate. Cooke and colleague have demonstrated elsewhere that the proposed four-­factor models are theoretically and methodologically inadequate as descriptions of the measurement model underpinning PCL-R ­ratings.8) It is important to distinguish between measures such as the PCL-R and the construct of psychopathy,8,9 the fundamental point being that psychopathy is not synonymous with the PCL-R; the PCL-R is merely one fallible measure of the construct. Adults with PPD form a distinct subgroup of individuals with antisocial behaviour problems. Most adults with PPD meet diagnostic criteria for antisocial personality disorder (ASPD),10 but

Lorraine Johnstone BA(Hons) Dip Clin Psych is Consultant Clinical Forensic Psychologist at the Directorate of Forensic Mental Health, Glasgow, UK, and Research Fellow at Glasgow Caledonian University. Her clinical and research interests include the development of psychopathic personality disorder, violence and risk assessment. Conflicts of interest: none declared. David J Cooke FBPsS FRSE is Head of Psychology at the Directorate of Forensic Mental Health, Glasgow, UK, Professor of Forensic Clinical Psychology at Glasgow Caledonian University and Visiting Professor at the University of Bergen, Norway. His research interests are violence, psychopathy and personality disorder. Conflicts of interest: none declared.

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Adolescents

Psychopathy is associated with criminality and violence,12,13 poor institutional adjustment,14 poor treatment responsivity,15 substance misuse,16 and other cluster B personality disorder traits.3 PPD is not associated with depression and anxiety.17 The cause of psychopathic personality disorder is unknown, however as with all personality disorders, biopsychosocial ­models are likely to be most productive. Neuropsychological, physiological, brain imaging and biochemical studies provide some support for underlying biological differences but whether these are causes or consequences is impossible to discern. On laboratory measures, those with PPD are distinct in terms of their neurocognitive and affective functioning.18 However, psychosocial experiences have been shown to be relevant to understanding psychopathy19 and environmental influences on the development of particular traits have been established. For example, parenting practices are relevant to the socialization of conscience and ­emotions.17 Finally, it is difficult to know the nature of relationships between biology and environment, as the nature of associations is complex; bi-directional, transactional and interaction effects are possible. It is likely that the same pattern of traits can be reached by different pathways (equifinality).

Items and factor structure of the PCL-R, PCL:YV and APSD PCL-R Items

PCL:YV Items

APSD Items

Factor 1: arrogant and deceitful interpersonal style Glibness/superficial charm Grandiose sense of self-worth Pathological lying Conning/ manipulative Factor 2: deficient affective experience Lack of remorse or guilt Shallow affect Callous/lack of empathy Failure to accept responsibility for own actions Factor 3: impulsive and irresponsible behavioural style Need for stimulation/ proneness to boredom Parasitic lifestyle Lack of realistic, long-term goals Impulsivity Irresponsibility Items remaining Poor behavioural controls Promiscuous sexual behaviour Early behaviour problems Many short-term marital relationships Juvenile delinquency Revocation of conditional release Criminal versatility

Factor 1: arrogant, deceptive interpersonal style Impression management Grandiose sense of self-worth Pathological lying Manipulation for personal gain Factor 2: affective experience Lack of remorse Shallow affect Callous/lack of empathy Failure to accept responsibility Factor 3: impulsive, irresponsible behaviour Stimulation-seeking Parasitic orientation Lacks goals Impulsivity Irresponsibility Items remaining Poor anger control Impersonal sexual behaviour Early behaviour problems Unstable interpersonal relationships Serious criminal behaviour Serious violations of conditional release Criminal versatility

Factor 1: callous and unemotional traits Concerned about schoolwork* Keeps promises* Feels bad or guilty* Concerned about the feelings of others* Does not show emotions Keeps the same friends* Factor 2: narcissism scale Emotions seem shallow Brags excessively Uses or cons others Teases others Can be charming, but seems insincere Becomes angry when corrected Thinks s/he is better than others Factor 3: impulsivity items Blames others for mistakes Acts without thinking Gets bored easily Engages in risky activities Does not plan ahead Items remaining Engages in illegal activities Lies easily and skilfully

Psychopathy in young offenders We now consider the extent to which research findings based on PCL:YV and APSD show convergence with the adult literature. Reliability of assessment procedures The PCL:YV has shown relatively high reliability4 but the APSD has shown poor interreliability,20 even between raters in the same setting.21 Prevalence Large-scale epidemiological data on PPD in adolescents is unavailable but it has been reported that, whilst most adolescent offenders meet diagnostic criteria for conduct disorder, only small numbers show significant PPD traits (20–30% of institutionalized adolescent males and 10% of those on probation).4,22 With regard to children, Frick reported a prevalence rate of between 1.23% and 3.46% in community samples using the APSD.23 Structure Consistent with the adult research, a three-factor model has been shown to provide the best fit for the PCL:YV (arrogant, deceptive interpersonal style; affective experiences; impulsive, irresponsible behaviour)24–26 and the APSD (narcissism; impulsivity; and callous-unemotional).27 However, there are important differences. For example, as shown in Table 1, ‘emotions seem shallow’ is associated with narcissism in the three-factor model of the APSD, whereas it is associated with the deficient affective experience in adults and adolescents. Attempts have been made to fit a variety of ‘four-factor’ models, however these attempts have been limited by significant conceptual and methodological problems.8

*  Items scored inversely.

Table 1

Construct validity In adolescent offenders, PPD traits are significantly associated with future offending but effect sizes are small, with considerable diversity.28 Other research has confirmed this finding. ­ Neither

only 25% of adults with an ASPD diagnosis meet diagnostic criteria for psychopathy.2,3 PPD traits are likely to drive, disinhibit or destabilize an individual and thereby increase the risk of ­offending.11

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total nor factor scores on the PCL:YV were predictive of general or violent recidivism over a 10-year period.29 With regard to the APSD, the CU factor has been shown to be predictive of more severe conduct problems.30 There is a positive relationship between scores on the PCL: YV and institutional misconduct, but once again, effect sizes are small.31 To our knowledge, the APSD has not been used in research concerning institutional misconduct with pre-pubescent children. Consistent with the adult literature, PPD traits in adolescents are positively associated with substance misuse problems32,33 and personality disorders,34 however, diverging from the adult findings, scores on the PCL:YV have shown a positive ­ association with axis I disorders.35

to establish the disorder as a coherent syndrome with strong evidence that it is a reliable and valid construct. Longitudinal research exploring the stability and developmental processes involved in this disorder also needs established. For some young offenders, such research is irrelevant as they may already be entrenched in their antisocial behaviour. In keeping with recommendations for practice,6,44 the use of assessments such as the PCL:YV and APSD should be undertaken with great care. These should be embedded within a comprehensive evaluation which involves a detailed analysis of differential hypotheses and due consideration given to developmental, temporal and contextual factors. Importantly, corroboration with other assessment tools will be necessary. In conclusion, there is clearly a valid case for studying psycho­ pathic-like traits in children and adolescents, but the application of this construct beyond the research arena where it may inform clinical decisions must be done with considerable care and caution. ◆

Stability Long-term follow-up studies regarding the stability of PCL-YV scores are not available. Research using the APSD has led to the conclusion that the tool shows ‘reasonable stability’ in repeated administrations of the APSD over a 4-year interval among a community sample of children.36 The absence of research delineating what and how psychopathic-like features manifest across the different developmental stages is a significant limitation. Inferring from other research, there is not absolute continuity between childhood temperament and behaviour and personality in later life.37 Indeed, with regard to behavioural concomitants of the disorder, adolescence is marked by increased involvement in antisocial behaviour in general and violence in particular, but desistance is common.33,38–40

References 1 Cleckley H. The mask of sanity. St. Louis, MO: Mosby, 1976. 2 Hare RD. Manual for the Revised Psychopathy Checklist. Toronto: Multi-Health Systems, 1991. 3 Hare RD. Manual for the Psychopathy Checklist, 2nd edn. Toronto: Multi-Health Systems, 2003. 4 Forth AE, Kosson DS, Hare RD. The Psychopathy Checklist: Youth Version. Toronto: Multi-Health Systems, 2003. 5 Frick P, Hare RD. The Antisocial Processes Screening Device. Toronto: Multi Health Systems, 2001. 6 Johnstone L, Cooke DJ. Psychopathic-like traits in childhood: conceptual and measurement concerns. Behav Sci Law 2004; 22: 1–23. 7 Edens JF. Unresolved controversies concerning psychopathy: implications for clinical and forensic decision-making. Prof Psychol Res Pr 2006; 37: 59–65. 8 Cooke DJ, Michie C, Skeem J. Understanding the structure of the Psychopathy Checklist – Revised. Br J Psychiatry 2007; 198(suppl 49): 39–50. 9 Skeem J, Cooke DJ. Is antisocial behaviour essential to psychopathy? Conceptual directions for resolving the debate. Psychol Assess (in press). 10 American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV), 4th edn. Washington, DC: American Psychiatric Association, 1994. 11 Cooke DJ, Michie C, Hart SD, Clark DA. Reconstructing psychopathy: clarifying the significance of antisocial and socially deviant behavior in the diagnosis of psychopathic personality disorder. J Personal Disord 2004; 18: 337–57. 12 Gendreau P, Goggin C, Smith P. Is the PCL-R really an ‘unparalleled’ measure of offender risk? Crim Justice Behav 2002; 29: 397–426. 13 Hemphill JF, Hare RD, Wong S. Psychopathy and recidivism: a review. Legal and Criminological Psychology 1998; 3: 139–70. 14 Hobson J, Shine J, Roberts R. How do psychopaths behave in a therapeutic community. Psychol Crime Law 2000; 6: 139–54. 15 Skeem JL, Mulvey EP. Applicability of the traditional and revised models of psychopathy to the Psychopathy Checklist: Screening Version. Psychol Assess 2003; 15: 41–55.

Aetiology The assumption of biological primacy as an aetiological basis for psychopathy is apparent in the juvenile literature. Wootton and colleagues found that problematic parenting predicted conduct problems in children who did not have co-occurring CU traits but not in children who also had CU traits.41 Blair and his colleagues have published many studies showing an association between various neurocognitive and emotional processing variables and CU traits.23 However, the route between brain and environment is not one way: cortical plasticity is evident across the lifespan.42 Many hypotheses exist about the aetiological basis of psycho­ pathy but little empirical data is available to provide a conclusive argument about what and how psychopathy develops. Such research will need to consider multiple pathways and processes. Treatment responsivity There is a dearth of literature concerning the treatment of psychopathic-like traits in adolescents and children. It would be premature to make assumptions about non-responsivity as this could serve to amplify rather than curtail the problems of young people with PPD. The adult literature suggests that modifications to the ways in which treatments are delivered, taking into account the particular needs of those with PPD, may be productive.43

Clinical implications The existing research provides a tentative link between the findings in the adult literature and the adolescent and child research. There are many priorities for future investigation. It is ­necessary

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16 Rutherford MJ, Alterman AI, Cacciola JS. Psychopathy and substance abuse: a bad mix. In: Gacono CB, ed. The clinical and forensic assessment of psychopathy: a practitioner’s guide. Mahwah, NJ: Lawrence Erlbaum Associates, 2000. 17 Lykken DT. The antisocial personalities. Hillsdale, NJ: Lawrence Erlbaum, 1995. 18 Patrick CJ, ed. Handbook of psychopathy. New York: The Guilford Press, 2006. 19 Marshall LM, Cooke DJ. The childhood experiences of psychopaths: a retrospective study of familial and societal factors. J Personal Disord 1998; 13: 211–25. 20 Frick P, Lilienfeld SO, Ellis ML, Loney BR, Sliverthorn P. The association between anxiety and psychopathy dimensions in children. J Abnorm Psychol 1999; 27: 383–92. 21 Blair RJR, Colledge E, Murray L, Mitchell DGV. A selective impairment in the processing of sad and fearful expressions in children with psychopathic tendencies. J Abnorm Child Psychol 2001; 29: 491–98. 22 Salekin RT, Neumman CS, Leistcto AR, DiCicco T, Duros RL. Construct validity of psychopathy in a young offender sample: taking a closer look at psychopathy’s potential importance over disruptive behaviour disorders. J Abnorm Psychol 2004; 113: 416–27. 23 Blair RJR, Mitchell D, Blair K. The psychopath: emotion and the brain. Oxford: Blackwell Publishing, 2005. 24 Dolan M, Rennie C. Psychopathic Checklist: Youth Version and Youth Psychopathic Trait Inventory: a comparison study. Pers Individ Dif 2006; 41: 779–89. 25 Salekin RT, Brannen D, Zalot AA, Leistco AR, Neumann CS. Factor structure of psychopathy in youth: testing the applicability of the new four factor model. Crim Justice Behav 2006; 33: 135–57. 26 Neumann CS, Kosson DS, Forth AE, Hare RD. Factor structure of the Hare Psychopathy Checklist: Youth Version (PCL:YV) in incarcerated adolescents. Psychol Assess 2006; 18: 142–54. 27 Frick P, Bodin SD, Barry CT. Psychopathic traits and conduct problems in community and clinic referred samples of children: further development of the Psychopathy Screening Device. Psychol Assess 2000; 12: 382–93. 28 Edens JF, Campbell JS, Weir J. Youth psychopathy and criminal recidivism. A meta-analysis of the Psychopathy Checklist measures. Law Hum Behav 2007. 29 Edens J, Cahill MA. Psychopathy in adolescence and criminal recidivism in young adulthood: longitudinal results from a multiethic sample of youthful offenders. Assessment 2007; 14: 57–64. 30 Christian R, Frick P, Hill N, Tyler LA, Frazer D. Psychopathy and conduct problems in children: subtyping children with conduct problems based on their interpersonal and affective style. J Am Acad Child Adolesc Psychiatry 1997; 36: 233–41. 31 Edens JF, Campbell JS. Identifying youths at risk for institutional misconduct: a meta-analytic investigation of the Psychopathy Checklist measures. Psychol Bull 2007; 4: 13–27. 32 Murrie DC, Cornell DG, Kaplan S, McConville D, Levy-Elkon A. Psychopathy scores and violence among juvenile offenders: a multimeasure study. Behav Sci Law 2004; 22: 49–67. 33 Corrado PR, Vincent GM, Hart SD, Cohen IM. Predictive validity of the Psychopathy Checklist:Youth Version for general and violent recidivism. Behav Sci Law 2004; 21: 829–46.

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34 Myers WC, Burkett RC, Harris HE. Adolescent psychopathy in relation to delinquent behaviours, conduct disorders, and personality disorders. J Forensic Sci 1995; 40: 436–40. 35 Schmidt F, McKinnon L, Chatta HK, Brownlee K. Concurrent and predictive validity of the Psychopathy Checklist: Youth Version across gender and ethnicity. Psychol Assess 2006; 18: 393–401. 36 Frick P, Kimonis ER, Dandreaux DM, Farrell JM. The 4 years stability of psychopathic traits in non-referred youth. Behav Sci Law 2003; 21: 1–24. 37 Caspi A. The child is father of the man: personality continuities from childhood to adulthood. J Pers Soc Psychol 2000; 78: 158–72. 38 Farrington DP. The Twelfth Jack Tizard Memorial Lecture. The development of offending and antisocial behavior from childhood: key findings from the Cambridge study in delinquent development. J Child Psychol Psychiatry 1995; 360: 929–64. 39 Moffitt TE. ‘Adolescence-limited’ and ‘life-course persistent’ antisocial behaviour: a developmental taxonomy. Psychol Rev 1993; 100: 674–701. 40 Odgers CL, Reppucci ND, Moretti MM. Nipping psychopathy in the bud: an examination of the convergent, predictive and theoretical utility of the PCL:YV among adolescent girls. Behav Sci Law 2005; 23: 743–63. 41 Wootton JM, Frick P, Shelton KK, Silverthorn P. Ineffective parenting and childhood conduct problems: the moderating role of callousunemotional traits. J Consult Clin Psychol 1997; 65: 301–08. 42 Grossman AW, Churchill JD, McKinney BC et al. Experience affects on brain development: possible contributions to psychopathology. J Child Psychol Psychiatry 2003; 44: 33–63. 43 Attrill G. Chromis: an intervention designed for psychopathic offenders (unpublished). 44 Seagrave D, Grisso T. Adolescent development and the measurement of juvenile psychopathy. Law Hum Behav 2002; 26: 219–39.

Further reading Patrick CJ. Handbook of psychopathy. Guilford Press, 2006.

Practice points • The construct of psychopathy may help inform our understanding of antisocial behaviour in children and adolescents • Research using the PCL:YV and APSD has produced findings similar to the adult literature, however there are important differences • We do not know what causes PPD, how it develops or manifests across the lifespan, whether it is a stable syndrome, whether it can be reliably assessed or whether it can be treated or prevented • With the commercial availability of the PCL:YV and the ASPD it is incumbent on practitioners to ensure that they are familiar with the strengths and limitations of these measures and the associated research

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