Antisocial personality disorder

Definition

Antisocial behavior is that which is verbally or physically harmful to other people, animals, or property, including behavior that severely violates social expectations for a given environment. Antisocial personality disorder in adults is also referred to as sociopathy or psychopathy.

Description

Antisocial behavior can be broken down into two components: the presence of antisocial (i.e., angry, aggressive, or disobedient) behavior and the absence of prosocial (i.e., communicative, affirming, or cooperative) behavior. Most children exhibit some antisocial behavior during their development, and different children demonstrate varying levels of prosocial and antisocial behavior. Some children—for example, the popular but rebellious child—may exhibit high levels of both antisocial and prosocial behaviors. Others—for example, the withdrawn, thoughtful child—may exhibit low levels of both types of behaviors.

High levels of antisocial behavior are considered a clinical disorder. Young children may exhibit hostility towards authority, and be diagnosed with oppositional-defiant disorder. Older children may lie, steal, or engage in violent behaviors, and be diagnosed with conduct disorder . A minority of children with conduct disorder whose behavior does not improve as they mature will go on to develop adult antisocial personality disorder.

A salient characteristic of antisocial children and adolescents is that they appear to have no feelings. They demonstrate no care for others' feelings or remorse for hurting others, and tend not to show their own feelings except for anger and hostility, and even these are communicated through aggressive acts and are not necessarily expressed through affect. One analysis of antisocial behavior is that it is a defense mechanism that helps children avoid painful feelings, or avoid the anxiety caused by lack of control over the environment.

Antisocial behavior may also be a direct attempt to alter the environment. Social learning theory suggests that negative behaviors are reinforced during childhood by parents, caregivers, or peers. In one formulation, a child's negative behavior (e.g., whining, hitting) initially serves to stop the parent from behaving in ways that are aversive to the child (the parent may be fighting with a partner, yelling at a sibling, or even crying). The child will apply the learned behavior at school, and a vicious cycle sets in: he or she is rejected, becomes angry and attempts to force his will or assert his pride, and is then further rejected by the very peers from whom he might learn more positive behaviors. As the child matures, "mutual avoidance" sets in with the parent(s), as each party avoids the negative behaviors of the other. Consequently, the child receives little care or supervision and, especially during adolescence , is free to join peers who have similarly learned antisocial means of expression.

Demographics

Mental health professionals agree, and rising rates of serious school disciplinary problems, delinquency, and violent crime indicate, that antisocial behavior in general is increasing. Thirty to 70% of childhood psychiatric admissions are for disruptive behavior disorders, and diagnoses of behavior disorders are increasing overall. A small percentage of antisocial children (about 3% of males and 1% of females) grow up to become adults with antisocial personality disorder, and a greater proportion suffer from the social, academic, and occupational failures resulting from their antisocial behavior.

Causes and symptoms

Factors that contribute to a particular child's antisocial behavior vary, but they usually include some form of family problems (e.g., marital discord, harsh or inconsistent disciplinary practices or actual child abuse , frequent changes in primary caregiver or in housing, learning or cognitive disabilities, or health problems). Attention deficit/hyperactivity disorder is highly correlated with antisocial behavior.

A child may exhibit antisocial behavior in response to a specific stressor (such as the death of a parent or a divorce ) for a limited period of time, but this is not considered a psychiatric condition. Children and adolescents with antisocial behavior problems have an increased risk of accidents, school failure, early alcohol and substance use, suicide , and criminal behavior. The elements of a moderate to severely antisocial personality are established as early as kindergarten. Antisocial children score high on traits of impulsiveness, but low on anxiety and reward-dependence—the degree to which they value, and are motivated by, approval from others. Yet underneath their tough exterior, antisocial children have low self-esteem .

Although antisocial personality disorder is only diagnosed in people over age 18, the symptoms are similar to those of conduct disorder, and the criteria for diagnosis include the onset of conduct disorder before the age of 15. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV-TR) , people with antisocial personality disorder demonstrate a pattern of antisocial behavior since age 15.

The adult with antisocial personality disorder displays at least three of the following behaviors:

• fails to conform to social norms, as indicated by frequently performing illegal acts, and pursuing illegal occupations
• is deceitful and manipulative of others, often in order to obtain money, sex, or drugs
• is impulsive, holding a succession of jobs or residences
• is irritable or aggressive, engaging in physical fights
• exhibits reckless disregard for the safety of self or others, misusing motor vehicles, or playing with fire
• is consistently irresponsible, failing to find or sustain work or to pay bills and debts
• demonstrates lack of remorse for the harm his or her behavior causes others

An adult diagnosed with antisocial personality disorder will demonstrate few of his or her own feelings beyond contempt for others. Authorities have linked antisocial personality disorder with abuse, either physical or sexual, during childhood, neurological disorders (which are often undiagnosed), and low IQ. Those with a parent with an antisocial personality disorder or substance abuse problem are more likely to develop the disorder. The antisocially disordered person may be poverty-stricken, homeless, a substance abuser, or have an extensive criminal record. Antisocial personality disorder is associated with low socioeconomic status and urban settings.

When to call the doctor

When symptoms of antisocial behavior appear, a child should be taken to his or her health care provider as soon as possible for evaluation and possible referral to a mental health care professional. If a child or teen reveals at any time that he/she has had recent thoughts of self-injury or suicide, or if he/she demonstrates behavior that compromises personal safety or the safety of others, professional assistance from a mental health care provider or care facility should be sought immediately.

Diagnosis

Antisocial behavior and childhood antisocial disorders such as conduct disorder may be diagnosed by a family physician or pediatrician, social worker, school counselor, psychiatrist, or psychologist. A comprehensive evaluation of the child should ideally include interviews with the child and parents, a full social and medical history, review of educational records, a cognitive evaluation, and a psychiatric exam.

One or more clinical inventories or scales may be used to assess the child, including the Youth Self-Report, the School Social Behavior Scales (SSBS), the Overt Aggression Scale (OAS), Behavioral Assessment System for Children (BASC), Child Behavior Checklist (CBCL), the Nisonger Child Behavior Rating Form (NCBRF), Clinical Global Impressions scale (CGI), and Diagnostic Interview Schedule for Children (DISC). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Treatment

The most important goals of treating antisocial behavior are to measure and describe the individual child's or adolescent's actual problem behaviors and to effectively teach him or her the positive behaviors that should be adopted instead. In severe cases, medication will be administered to control behavior, but it should not be used as a substitute for therapy. A child who experiences explosive rage may respond well to medication. Ideally, an interdisciplinary team of teachers, social workers, and guidance counselors will work with parents or caregivers to provide services to help the child in all aspects of his or her life: home, school, work, and social contexts. In many cases, parents themselves need intensive training on modeling and reinforcing appropriate behaviors in their child, as well as in providing appropriate discipline to prevent inappropriate behavior.

A variety of methods may be employed to deliver social skills training, but especially with diagnosed anti-social disorders, the most effective methods are systemic therapies which address communication skills among the whole family or within a peer group of other antisocial children or adolescents. These probably work best because they entail actually developing (or redeveloping) positive relationships between the child or adolescent and other people. Methods used in social skills training include modeling, role-playing, corrective feedback, and token reinforcement systems. Regardless of the method used, the child's level of cognitive and emotional development often determines the success of treatment. Adolescents capable of learning communication and problem-solving skills are more likely to improve their relations with others.

Unfortunately, conduct disorders, which are the primary form of diagnosed antisocial behavior, are highly resistant to treatment. Few institutions can afford the comprehensiveness and intensity of services required to support and change a child's whole system of behavior. In most cases, for various reasons, treatment is terminated (usually by the client) long before it is completed. Often, the child may be fortunate to be diagnosed at all. Schools are frequently the first to address behavior problems, and regular classroom teachers only spend a limited amount of time with individual students. Special education teachers and counselors have a better chance at instituting long-term treatment programs—if the student stays in the same school for a period of years. One study showed teenage boys with conduct disorder had had an average of nine years of treatment by 15 different institutions. Treatments averaged seven months each.

Studies show that children who are given social skills instruction decrease their antisocial behavior, especially when the instruction is combined with some form of supportive peer group or family therapy . But the long-term effectiveness of any form of therapy for anti-social behavior has not been demonstrated. The fact that peer groups have such a strong influence on behavior suggests that schools that employ collaborative learning and the mainstreaming of antisocial students with regular students may prove most beneficial to the antisocial child. Because the classroom is a natural environment, learned skills do not need to be transferred. By dividing the classroom into groups and explicitly stating procedures for group interactions, teachers can create opportunities for positive interaction between antisocial and other students.

Prognosis

Early and intensive intervention is the best hope for children exhibiting antisocial behaviors or diagnosed conduct disorder. For those who grow into adults with antisocial personality disorder, the prognosis is not promising; the condition is difficult to treat and tends to be chronic. Although there are medications available that could quell some of the symptoms of antisocial personality disorder, noncompliance or abuse of the drugs prevents their widespread use. The most successful treatment programs are long-term, structured residential settings in which the patient systematically earns privileges as he or she modifies behavior.

Prevention

A supportive, nurturing, and structured home environment is believed to be the best defense against anti-social behavioral problems. Children with learning disabilities and/or difficulties in school should get appropriate academic assistance. Addressing these problems when they first appear helps to prevent the frustration and low self-esteem that may lead to antisocial issues later.

Parental concerns

A child with antisocial behavioral problems can have a tremendous impact on the home environment and on the physical and emotional welfare of siblings and others sharing the household, as well as their peers at school. While seeking help for their child, parents must remain sensitive to the needs of their other children. This may mean avoiding leaving siblings alone together, getting assistance with childcare, or even seeking residential or hospital treatment for the child if the safety and well-being of other family members is in jeopardy. Parents should also maintain an open dialog with their child's teachers to ensure that their child receives appropriate educational assistance and that classmates are not put at risk.

See also Aggression; Conduct disorder ; Oppositional defiant disorder .

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSMIV-TR). Washington, DC: American Psychiatric Press, Inc., 2000.

Connor, Daniel. Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment. New York: Guilford Press, 2002.

Eddy, J. Mark. Conduct Disorders: The Latest Assessment and Treatment Strategies. Kansas City, MO: Compact Clinicals, 2003.

PERIODICALS

Cellini, Henry R. "Biopsychological Treatment of Antisocial and Conduct-Disordered Offenders." Federal Probation 66, no. 2 (September 2002): 78+.

Connor, Daniel F. "Aggression and Antisocial Behavior in Youth." Brown University Child & Adolescent Behavior Letter 18, no. 9 (September 2002): 1+.

ORGANIZATIONS

The American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., N.W., Washington, D.C. 20016-3007. (202) 966-7300. Web site: http://www.aacap.org

WEB SITES

The National Mental Health Association. http://www.nmha.org.

NYU Child Study Center. Changing the Face of Child Mental Health. http://www.aboutourkids.org.

Paula Ford-Martin