Rationale for Early Intervention in Personality Disorder: The Future for Forensic Services

1. Rationale for Early Intervention in Personality Disorder: The Future for Forensic Services NCATS Research Unit National Child Assessment & Treatment Service (NCATS) (Formerly The Young Abusers Project) Eileen Vizard, Eamon Mc Crory, Elly Farmer Forensic Adolescent Network. SAH. 3.10.08

2. Outline of Presentation • Setting the Scene: 1. Delinquency & Crime 2. Personality Disorder & Psychopathy 3. Childhood Origins of Personality Disorder • Home Office study • Cost benefits of early intervention • Future for Forensic Services • Research implications Forensic Adolescent Network. SAH. 3.10.08

3. 1. Delinquency & Crime • A small number of people are responsible for much crime in adolescence & adult life: 6% responsible for half the convictions up to age 32 years Farrington & West 1993 • < 5% of male population responsible for 50 – 70% of all violent crime Moffit 1993; Hodgins 1994 • Males first convicted at an earlier age (10 – 13 yrs) became the most persistent offenders with careers spanning 9.9 yrs & averaging 8.8 offences Farrington 1998 Forensic Adolescent Network. SAH. 3.10.08

4. 2. Personality Disorder & Psychopathy • Psychopathy describes a narrower group of offenders (15-30%) than ASPD (50-80%)Hare 1991; Robins 1991 • But most psychopaths meet criteria for ASPD • ‘Thus, across several studies, three quarters of adults displaying serious antisocial behaviour had displayed the syndrome of childhood antisocial behaviour. These findings have been influential in recent conceptions of antisocial or psychopathic personality disorder.’ Blackburn 1989 • Juvenile psychopathy linked with deprivation for > 70yrs Bender,1947;Bowlby, 1952 Moffit 1993 Forensic Adolescent Network. SAH. 3.10.08

5. 2. Personality Disorder & Psychopathy Personality Disorder does not suddenly manifest as a complete problem in adulthood, it has its origins and early indicators in childhood and adolescence ? • Can we identify an early at risk group? • What are the early developmental precursors? • Would early identification facilitate improved treatment and outcome? Forensic Adolescent Network. SAH. 3.10.08

6. 3. Childhood Origins of Personality Disorder • Robust evidence on delinquency trajectories Broidy et al 2003; Loeber & Stouthamer-Loeber 1998; Moffitt et al 1996; Moffitt et al 2002; Patterson et al 1989 ;Raskin-White et al 2001; Chung et al 2002 • Links between delinquency, CD & ASPD Rutter 1998; Farrington 1995; Moffit 1993 • Boys with both CD & CU traits share many features with adult psychopathy, e.g.: less ability to recognise sadness, impaired moral reasoning & empathy, higher IQ scores, do not understand the negative consequences of aggressive behaviour & less responsive to punishment Hodgins 2007 Forensic Adolescent Network. SAH. 3.10.08

7. 3. Childhood Origins of Personality DisorderDevelopmental Trajectories Adult Offending • ‘Life-Course Persistent’ trajectory - early neuro-psychological and environmental risk • Early differences in cognitive, behavioural and personality functioning. • Similar presentation with ‘Adolescent Limited’ individuals during adolescent period. (Moffitt, 1993) Good Outcome Infancy Childhood Adolescence Adulthood Forensic Adolescent Network. SAH. 3.10.08

8. 3. Childhood Origins of Personality Disorder • Not all badly behaved young children go on to develop CD/ASPD: Of the 15% of 5 year olds with ODD, < half of these will become 17 yr olds with CD Scott/Home Office 2002; Every Child Matters 2003 • But........... Increasingly strong evidence of developmental continuity in CU traits from adolescence into adulthood Lynam 2007 Forensic Adolescent Network. SAH. 3.10.08

9. 3. Childhood Origins of Personality Disorder • So, should Personality Disorder emerging in childhood be seen as a developmental disorder? • If so, this could have important implications for identification and intervention Vizard et al 2004; 2007 • Insensitivity to punishment (e.g. ‘time out’) is a key feature of psychopathy. ‘Time out’ parent training is ineffective in children with CD + CU traits Hodgins 2007; Dadds 2003 & 2005 Forensic Adolescent Network. SAH. 3.10.08

10. “ Links between juvenile sexually abusive behaviour and emerging severe personality disorder traits in childhood ” Results of a 3 year Home Office funded study November 2006 www.dspdprogramme.gov.uk/pages/publications/publications1.php NCATS Research Team Eileen Vizard Nicole Hickey Eamon McCrory Lesley French Forensic Adolescent Network. SAH. 3.10.08

11. Home Office Study • n=280 cases seen at NCATS (YAP) (1992 – 2003), a 4th tier specialist assessment and treatment service • Case file review: detailed developmental coding schedule • File based scoring of the PCL-YV • Offenders Index data Forensic Adolescent Network. SAH. 3.10.08

12. Aims of Study • To describe the characteristics of a UK cohort of clinically high risk children and young people presenting with sexually abusive behaviour • To explore whether ‘age of onset’ could identify distinct subgroups of juvenile sexual abuser whose developmental trajectories differed in relation to their psychosocial characteristics, antisocial behaviour and conviction profiles • To explore whether high levels of ESPD traits could identify a subgroup of juvenile sexual abusers (JSA’s) with a distinct developmental trajectory in relation to psychosocial characteristics, antisocial behaviour and conviction profile • To provide practical guidance for clinicians, policy makers and researchers in relation to the implications of the findings Forensic Adolescent Network. SAH. 3.10.08

13. Emerging Severe Personality Disorder (ESPD) Traits • Severe Conduct Disorder traits (CD) 12 behavioural criteria (e.g. aggression, stealing, running away), n=128 (46%) scored above the sample mean of 5.3 • Severe Personality Disorder traits 20 item PCL-YV (interpersonal, affective, behavioural), n=73 (36%) scored above the sample mean of 8.8. Forensic Adolescent Network. SAH. 3.10.08

14. Defining ESPD traits ESPD Above sample mean on conduct disorder and PCL:YV vs Non-ESPD Below sample mean on conduct disorder or PCL:YV n=54 NCATS sample N = 203 n=149 Forensic Adolescent Network. SAH. 3.10.08

15. ESPD vs. non-ESPD:Psychosocial characteristicsRed type = Psychosocial predictors of Early Onset of SAB Forensic Adolescent Network. SAH. 3.10.08 (*p=.05, ** p=.01)

16. ESPD vs. non-ESPD:Psychosocial characteristics (*p=.05, ** p=.01) Forensic Adolescent Network. SAH. 3.10.08

17. ESPD vs. non-ESPD:SHB victims pre & post adolescence Forensic Adolescent Network. SAH. 3.10.08 (*p=.05, ** p=.01)

18. ESPD vs. non-ESPD:Sexually abusive behaviour pre & post adolescence ++ abusing more strangers, abusing child and adult victims (*p=.05, ** p=.01) Forensic Adolescent Network. SAH. 3.10.08

19. ESPD vs. non-ESPDDevelopmental continuity of non-sexual anti-social behaviour Forensic Adolescent Network. SAH. 3.10.08 (*p=.05, ** p=.01)

20. ESPD vs. non-ESPD:Lifetime conviction profile (n=196) Forensic Adolescent Network. SAH. 3.10.08 (*p=.05, ** p=.01)

21. Study Conclusions • ‘To explore whether high levels of ESPD traits could identify a subgroup of juvenile sexual abusers (JSA’s) with a distinct developmental trajectory in relation to psychosocial characteristics, antisocial behaviour and conviction profile’ • A subgroup of children on a distinct trajectory was identified Forensic Adolescent Network. SAH. 3.10.08

22. Cost Benefits of Early Intervention • Cost of youth crime £1 B p.a. Audit Commission 1999 • Children with CD at 10 yrs in UK would have cost public services £70,000.00 by 27 yrs Scott 2001 • Children with psychopathic/CU traits likely to cost public services much more: • Range of costs for CD = £5,411 - £40,896 p.a. Knapp 1999 • Cost effectiveness for some treatments vs ‘usual services’ e.g. MST Utting 2007 Forensic Adolescent Network. SAH. 3.10.08

23. Future of Forensic Services • ‘One size fits all’ not practical: tiered intervention needed • Community awareness raising programmes using the media, et T.V. etc, e.g. Triple P Sanders et al in Utting 2007 • Primary prevention services in the form of multi-agency support and skills based training for parents and children, e.g. Family Nurse partnerships Utting 2007 • Local CAMHS services to provide screening and assessment for children and young people at risk of ESPD • A national network of regional, specialist forensic services to provide community based, non residential consultation, assessment and treatment for the most disturbed young people with ESPD • A small number of specialist residential services for young people with severe PDs or DSPDs Hickey et al 2006 Forensic Adolescent Network. SAH. 3.10.08

24. Research Implications • Follow up studies of delinquent youth to map trajectories • Treatment outcome studies with 10 - 15 year follow up as a minimum • Novel treatment approaches for high risk/high harm children with CU traits & their families Forensic Adolescent Network. SAH. 3.10.08

25. References • Audit Commission (1999).Children in Mind: Child and Adolescent Mental Health Services. Abingdon: Audit Commission Publications • Blair, J. et al. (2006). The development of Psychopathy. Journal of Child Psychology and Psychiatry, 47: 262-76. • Forth, A.E., Kosson, D. and Hare R.D. (2003) The Hare Psychopathy Checklist: Youth Version. Toronto: Multi-Health Systems. • Frick, P.J., Cornell, A.H., Bodin, S.D., Dane, H.A., Barry, C.T. and Loney, B.R. (2003) Callous-Unemotional traits and developmental pathways to severe conduct problems. Developmental Psychology, 39(2), 246–260. • Hawes, D.J. & Dadds, M.R. (2005). The treatment of Conduct Problems in Children with callous-unemotional traits. Journal of Consulting and Clinical Psychology, 73(4), 737-741. • Hickey, N., Vizard, E., French, L., & McCrory, E. (2006). Links between juvenile sexually abusive behaviour and emerging severe personality disorder traits. Home Office Report: London http://www.dh.gov.uk/assetRoot/04/14/02/70/04140270.pdf Forensic Adolescent Network. SAH. 3.10.08

26. References • Lynam, D.R., Caspi, A., Moffitt, T.E., Loeber, R. & Stouthhamer-Loeber, M. (2007). Longitudinal evidence that psychopathy scores in early adolescence predict adult psychopathy. Journal of Abnormal Psychology, 116(1), 155-165. • Moffitt, T. E. (1993) Adolescence limited and life course persistent antisocial behaviour: A developmental taxonomy. Psychological Review 100: 674-701. • Scott, S., Knapp, M., Henderson, J. & Maughan, B. (2001). Financial cost of social exclusion: follow up[ study of antisocial children into adulthood. British Medical Journal, 323 (7306) p.191 • Utting, D., Monteiro, H. & Ghate, D. (2007). Interventions for children at risk of developing antisocial personality disorder. Report to the Department of Health and the Prime Minister’s Strategy Unit. Policy Research Bureau. London • Viding, E., Blair, J. R., Moffitt, T. E., & Plomin, R. (2004). Evidence for substantial genetic risk for psychopathy in 7-year-olds. Journal of Child Psychology and Psychiatry, 45, 1– 6. • Vizard,E., Hickey,N., McCrory,E. (2007). Developmental trajectories associated with juvenile sexually abusive behaviour and emerging severe personality disorder in childhood: The results of a three year U.K. study. British Journal of Psychiatry, 190 (supplement), 27-32. Forensic Adolescent Network. SAH. 3.10.08