Dr Lorraine Johnstone Consultant Clinical Forensic Psychologist

Visiting Professor/Clinical Lead, IVY Head of Child and Family Clinical Psychology

Associate Fellow of the British Psychological Society

Aims and Overview And a picture paints a thousand words

The problem of youth violence

The Billion Dollar Question Will they do it again?

The whole is greater than the sum of the parts

Risk factors for youth violence

Fitting a square peg into a round whole Youth Psychopathy AKA the Holy Grail

‘The chicken or the egg’

Attachment, complex trauma or psychopathy

‘Don’t throw the baby out with the bath water’ Using Formulation to Make Sense of Psychopathic-Like Traits

And a picture paints a thousand words…

Risk Factors

Individual/Temperamental

Developmental

Family

Community

Peer

The Billion Dollar Question: Will they do it again?

Age Crime Curve

Persistent and Serious

Conduct Problems

Psychopathy

Antisocial Personality

What is psychopathy?

Early conceptualisations

"Likeable," "Charming," "Intelligent," "Alert," "Impressive," "Confidence-inspiring”

“unreliability” “Untruthfulness” “Lack of remorse and shame” “Pathological Egocentricity” “Incapacity for love”

Criminality Violence Poor institutional adjustment Poor treatment responsivity Substance misuse Cluster B Personality Impaired neurocognitive and affective functioning

Etiological Basis

• A biological disorder

“psychopathy does not suddenly spring, unannounced, into existence in adulthood. The precursors…first reveal themselves early in life” Hare (1994)

Benjamin

Colleen

Hare Psychopathy Checklist Youth Version: PCL-YV, Forth, Kosson & Hare, (2003)

“from the school yard to the prison yard” (MHS)

Antisocial Process Screening Device (ASPD; Frick & Hare, 2001)

“the APSD screens for Antisocial Personality Disorder or psychopathy. The child is rated on a dimensional scale that probes the characteristic psychopathic pattern”

• In 2013, the DSM-IV made it permissible for clinicians to include a CU specifier when diagnosing conduct disorder

• What that means is identifying those children that are, according to some, showing precursors, if not actual, characteristics of psychopathy - there are important implications of this!

1. Lack of Remorse or Guilt: Does not feel bad or guilty when he/she does something wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules. The person rarely admits to being wrong and typically blames others for any negative consequences which result from his or her actions. 2. Callous-Lack of Empathy: Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of his or her actions on him or herself, rather than their effects on others, even when they result in substantial harm to others. 3. Unconcerned about Performance: Does not show concern about poor/problematic performance at school, work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance. 4. Shallow or Deficient Affect: Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions “on” or “off” quickly) or when emotional expressions are used for gain (e.g., emotions displayed to manipulate or intimidate others).

• More severe conduct problems (Christian et al., 1997) • Higher scores on measures of thrill and adventure seeking (Frick et al.,

2003; Frick et al., 1999) • Lower sensitivity to cues to punishment when a reward-oriented response

set is primed (O’Brien and Frick, 1996; Frick et al., 2003) • Lower levels of reactivity to threatening and emotionally distressing

stimuli (Blair, 1999) • Less distress to negative effects of their behaviour on others (Blair, 1997) • Impaired ability to recognize fearful and sad facial expressions and sad

vocal tones (Blair et al., 2001; Stevens et al., 2001) • Impairments in moral reasoning and empathic concerns towards others

(Blair, 1999) • Maladaptive dimensions of narcissism (Barry et al., 2003) • Support for the biological basis of the disorder

A valid contstruct

Voila!

Richter (1997)

Level 3:

Formulation-led, eclectic treatment

Level 2:

Specialist Assessment

Level 1:

Consultation

Brief Illustrations

• “John” – referred by consultant psychiatrist and clinical psychologist – has threatened to perpetrated a sexual homicide; has entered unknown females premises; has history of cruelty to animals including decapitation (multiple protocols – SAVRY, RSVP, THREAT, sexual homicide literatures)

• “Gemma” – referred by social worker. Complex presentation with multiple risks including fire-raising, self-harm, indecent exposure, thoughts of sexually assaulting younger sibling, extreme aggression towards staff and others (multiple protocols SAVRY, Northgate and RSVP but note limited data for girls).

• “Harry” – referred by police; distributing right wing and violent extremism materials; attempting to purchase bomb making materials via internet; openly endorses the use of violence for political ends; advocates Nazism and other extremist philosophies; attempting to form networks (SAVRY and VERA)

• “Jake” – referred by secure estate; convictions x3 rape; ongoing violence towards staff and peers; aggressive towards family; highly negative attitudes towards females and past victims; due for return to local community. (RSVP and SAVRY)

• “Lenny” – hx of raping x2 toddlers (sodomy) and sexual assault of vulnerable peer; had constant supervision since (around 3 years), due to exit childcare system; remains preoccupied with sexually explicit and pornographic materials and openly admits that would take an opportunity to offend against a child.

Historical Risk Factors

Historical Risk Factors High Moderate Low Not Rated

1. History of violence 38 4 0 0

2. History of nonviolent offending 26 8 7 1

3. Early initiation of violence 23 13 4 2

4. Past supervision/intervention failures 21 13 4 4

5. History of self-harm or suicide attempts 9 17 15 1

6. Exposure to violence in the home 28 4 6 4

7. Childhood history of maltreatment 28 4 7 3

8. Parental/caregiver criminality 21 6 12 3

9. Early caregiver disruption 28 11 2 1

10. Poor school achievement 29 8 2 3

Social/Contextual Factors

Social/Contextual Risk Factors H M L Not Rated

11. Peer delinquency 22 8 9 3

12. Peer rejection 28 9 4 1

13. Stress and poor coping 38 3 0 1

14. Poor parental management 31 7 2 2

15. Lack of personal/social support 20 17 4 1

16. Community disorganisation 13 6 16 7

Individual Factors

Individual/Clinical Risk factors

17. Negative attitudes 33 7 1 1

18. Risk taking/impulsivity 34 3 3 2

19. Substance use difficulties 17 4 19 2

20. Anger management problems 34 4 2 2

21. Low empathy/remorse 29 3 1 9

22. Attention deficit hyperactivity difficulties 13 4 23 2

23. Poor compliance 31 9 0 2

24. Low interest/commitment to school 20 14 5 3

Psychopathy Developmental

Disorder

Attachment and Complex

Trauma

Psychosis

Axis 1 (e.g. PTSD)

Substance use

Attachment Theory

Trauma, abuse and neglect

Impact of trauma and neglect

Attachment Styles

Models of Developmental Trauma

Hypervigilance

Dissociation and fragmented

consciousness

Affect dysegulation

Poor self-concept

Impaired world view

Hypervigilant to threat and preparedness to act…

• Poor behavioural controls

• Impulsivity

• Aggressivity

False Affect

• Inconsistent emotions

• Use of charm

• Manipulation

Dissociation

• Shallow affect • Lack of empathy • Lack of remorse As a ‘disconnect’ as opposed to absence of emotion Divorce between event and emotion Driving behavioural reenactments

Poor self-concept

‘The best defense

is offence’

Narcissism develops as a defense against early experiences of ineptness, shame and guilt experienced via abuse

Impaired world view

• Foreshortened future

• Lack of planfulness

• Risk taking

Beth Thomas

https://www.youtube.com/watch?v=ME2wmFunCjU

Square peg, round hole

But, don’t throw the baby out with the bathwater

An either or position is futile

Making sense of this complexity

• Formulation: tell the story…

– Analysis and description of the problem

– Temporal sequencing of the problem development mapped with significant attachment or trauma events

– Pragmatic formulation – 4 Ps

– Narrative with postulated mechamisms

– Reliability and validity check