Tuesday, June 26, 2012
In my line of work as a therapist working with severely disturbed children, I have handed out many diagnoses of Conduct Disorder and all kids have had similar symptoms as well as similar origins. Most are given this disorder due to serious rule violations (truancy from school or running away from home), deceitfulness (lying about where they are going), theft (stealing from family or local stores), and other negative activities such as drug use, gang activity, etc. One last category included in the diagnosis is of course harm to other people or harm to animals. In nearly all my cases, harm to others has included fighting with peers at school; in rare cases, it was fighting with staff at their school or group homes. All were impulsive acts, poorly thought out, all fueled by anger or pain, and while some did not openly express remorse toward their victims, there was an element of emotional response: anger for being caught and punished or blame toward the victim for upsetting them (typical to avoid self-blame and thus remorse).
In Antisocial Personality Disorder, aggression and acts of violence towards others are rarely impulsive. These behaviors are usually planned and carefully calculated. A premeditated act, there is no crime of passion or rage, just cold, undeserved punishment against some defenseless victim. A good example of such would be Timothy McVeigh, who for months plotted a terrorist attack against the Alfred P. Murrah Federal Building in Oklahoma City. He had no particular victims in mind, no one who upset him other than the US Government. McVeigh detonated a car bomb which caused over $500 million in damage and killed 168 people. When he learned there was a daycare in the building, he wrote the lives of 19 children off as “collateral damage”. He remained calm and collected throughout his arrest, questioning, trial and death. In the remaining years of his life before being executed, he never expressed remorse for his actions.
While it is difficult to imagine a child as cold-hearted as McVeigh, to assume that such characteristics arise purely in adulthood is absurd. Signs and symptoms present themselves early in life. Ted Bundy had such an incident when he was 5, where he stood by his aunt’s bed while she slept. When she awoke, she found him with a devilish grin, watching intently. As she became more alert and aware of her surroundings, she found that she was surrounded by a collection of knives laid on the bed, points directed inward toward her. The book “Children Who Kill" also gives several accounts of disturbed children engaging in acts of cold murder and torture far beyond typical problem children. And I have had the unfortunate business in my 21 months of work as a therapist to come across two such kids.
Both were six years old. My first was much harder to diagnosis: he presented with a mosaic of symptoms, bits and pieces of disorders never quite coming together to conclusively provide one concrete diagnosis. His symptoms ranged from possible autism, Aspergers, or developmental delay, Conduct Disorder or Oppositional Defiance, anxiety, depression, or bipolar disorder. He was moody, most times without antecedent, which would throw him into fits of rage that would last for several hours, or an abundance of depression, triggering crying fits for days. He also presented with a remarkable ability to control his emotions and behaviors, having fits and tantrums at home but not any issues at school. Even in a brief exchange during therapy, while I was explaining that therapy was a safe place to talk about our thoughts and feelings, he angrily retorted “I KNOW!" Taken slightly aback by this abrupt outburst, I calmly addressed it, asking why he felt so frustrated. His physique changed in the flash of a moment: his hunched shoulders sloped, his furrowed brow relaxed, his expression almost angelic, and he sat back and cooly responded “Nothing, I’m fine”, as if he had been caught with his hand in the cookie jar and tried to cover the evidence. He acted aggressively towards his younger brother, 3, whom he would drag around the house from room to room on their tile floors by a small limb, or whom he would calmly walk up to him and without warning scream inches from his face and frighten him to tears. Previous therapists could not pinpoint a disorder, and my task was no easier. While my supervisor pushed for Conduct, at the time to me a conduct disorder diagnosis was a life sentence on a dark road to sociopathy. He was given a provisional diagnosis of conduct, but it wasn’t until 8 months later that I was no longer given an option. A call from his frightened mother informed me that he had killed a duck at the local park, and she believed it was intentional. While somewhat fantastic, she relayed the tale of woe, that he, a pitcher for his local little league with a strong arm, had collected a pinecone, approached a duck by the riverbank, and threw the pinecone full force at the duck’s head. The duck began seizing, no doubt from a hemmorhage, and flopped over in the water, dead. Mom reported he did not seem phased by the incident and did not show remorse. When I later asked him what his intent was, he stated he “wanted to see what would happen”. He later confided that he had the option between the duck and a turtle that was also in the water, but noting the turtle’s protective shell, he stated “I knew if I hit the turtle, nothing would happen, he would just swim away, so I threw it at the duck”. Chilled by this calculated thought process, I reluctantly listed Conduct Disorder on his file.
My most recent case, I cannot go into detail with given that the case is still open, however he presents with a less complex case, nearly no mood lability or developmental delay but similar symptoms of disturbances which resulted in the death of an animal. Both children we exceptionally bright, both came from families with histories of significant mental health issues.
What has become apparent is that in comparison to my typical conduct cases, these children are in a class all their own. While Conduct Disorder has been generally considered the childhood APD, the connection between Conduct and Antisocial Personality Disorder is built on nothing more than a mere resemblance of one another. As previously stated, APD lacks the crucial component of humanity: empathy and care for one another, regret and remorse for our own behaviors, which is not necessarily reflected in CD. But even if the DSM could create a more appropriate diagnosis for children presenting with sociopathy, would the field allow it? Much like my reluctance to diagnose a 6 year old with such a dismal label, many others would most likely be just as apprehensive to diagnose a child with a damning sociopathy label. But as with my dilemma, my concern for labeling a patient and my hesitation to do so did not bring that duck back to life, and it did not make my patient’s difficulties disappear. If anything, it only delayed receiving more appropriate treatment. While labels can be hurtful, refusing to diagnose for fear of social stigma can be far more detrimental and as a therapist it is ethically unsound.
Dan Waschbusch, a researcher at Florida International University, has continued his study in children presenting with similar symptomology as my cases, and even one child named Michael was an almost exact replicate of my first kid with moody lability, hysterical outbursts, calculated aggression and violence toward his siblings and amazing mood control. Waschbusch described the condition as “Callously Unemotional Children”, and began a research camp where many children with the same affliction were sent to be observed and treated. The level of manipulation was immeasurable and bringing these children together could have been a recipe for disaster. Many children ended up worse, some remained the same, few improved, though Washbusch maintains that early intervention and intensive treatment could drastically improve the chances of these children growing into productive members of society. I am not so sure that I agree at this point and time, as an effective treatment cannot have been developed yet; typical behavioral interventions are probably ineffective as a simple system of rewards and consequences mean little to children who struggle with apathy. Certain medicinal interventions have been ruled out such as Ritalin, which would decrease any impulsivity the child suffered from and allow them more time and mental clarity to plan and coordinate more intricate attacks. In residential or treatment facilities they would be grouped with other children either with the same symptoms which they could pair with and learn from, or in facilities with children of different diagnoses they could dominate or harm. But no one wants to write any case off as being hopeless or untreatable and we have to try, at the very least to intervene when it might still make a difference.
It is impossible to claim that Antisocial tendencies don’t exist in children, and it has been demonstrated that it is inappropriate to lump preliminary APD into the Conduct Disorder category. On the other side of the scales lies the concern of wrongly diagnosing a child. What needs to be developed is not only an appropriate diagnosis and supporting criteria, but diagnostic tools to assist in accurately recognizing this disorder in children. Only when that path is paved can we begin to explore and create more effective treatments and help these kids before it’s too late.