Adverse Childhood Experiences and criminality

1. Adverse Childhood Experiences and criminality By Gavin Baker

2. agenda • Introduction • Intersection of Criminal Behavior and Mental Health • Maladaptive Personality Debate • History of Antisocial Personality Disorder (ASPD) • Convergence of Neuroscience and Epidemiology • Arizona and ACEs • Trauma, ACEs, and Criminal Offending • Relationship of ACEs and Future Adult Offending, Mental Illness, and ASPD

3. introduction Gavin Baker is a 4th year graduate student at the Arizona School of Professional Psychology, at Argosy University. He completed a 6-year career as a teacher, coach, and administrator prior to beginning his doctoral studies. He holds two Master’s Degrees in Education and Clinical Psychology and is completing his final year of doctoral training before beginning his full-time Pre-doctoral internship. Gavin has performed duties as a practicum student at the Arizona Department of Juvenile Corrections, conducted psychological evaluations in adult detention, and currently functions as a subcontractor for Correctional Health Services conducting restoration education and evaluation for competency to stand trial for the Maricopa Superior Courts under the supervision of a licensed psychologist.

4. Intersection of Criminal behavior and mental health • Free will/choice • Culpability, criminal responsibility • Brain-behavior relationship • Capacity to know right from wrong • Guilty Except Insane • Competence to stand trial

5. Intersection of Criminal behavior and mental health

6. Maladaptive Personality vs. mental illness • The conceptualization of personality has been vociferously debated for over a century • A consensus emerged that individual personality developed largely from two sources, genetic temperament and cumulative experience

7. DSM Personality debate: dimensional vs. categorical • In the 1950s, Ainsworth and Bowlby suggested that attachment to a primary caregiver in early childhood substantially influenced personality and psychological development throughout adulthood • Theorists began identifying maladaptive personality syndromes that ultimately were included in the early editions of the DSM (American Psychiatric Association, 1952; APA, 1968; APA, 1980) • Some experts argued for a dimensional conceptualization of personality such as the comprehensively studied Five-Factor Model; however, it was predominantly based on normal populations (Costa & Widiger, 2002) • At the time, diagnoses of mental disorders were also largely unreliable • Consequently, the DSM-III adopted the categorical system based on medical models of disease classification in the 1980s (APA, 1980; Costa & Widiger, 2002), which resulted in the primary criteria for ASPD

8. dimensional vs. categorical • The categorical model presumes that each personality disorder has a cluster of traits and/or behaviors that separates it from normal personalities • The dimensional model presumes that personality features or traits have varying levels or dimensions along multiple spectrums (e.g. Autism Spectrum Disorder)

9. Problems with current categorical system • The number of criteria required for diagnosis has always been an arbitrary number, despite the quality that an either or diagnosis conveys (Oldham, 2015) • The broad range of criteria also allows for substantial differences amongst individuals diagnosed with the same disorder (Oldham, 2015) • I.E., there are 256 ways that 5 out of 9 criteria for the borderline personality disorder can be configured, and two patients could receive this diagnosis but share only one criterion • Problematic over diagnosis of Conduct Disorder and ASPD (Ogloff et al., 2006) • Inconsistent with the current science and professional trends concerning mental health disorders, which emphasizes disorders within a spectrum (e.g. Autism Spectrum Disorder)

10. Psychopathy • In 1960s and 1970s, Cleckley’s Checklist was developed to identify the syndrome of psychopathy, which but was not included in the DSM-III • Robert Hare borrowed core traits from Cleckley to develop the Psychopathy Checklist that was later revised (PCL-R-2), Dr. Hare believes that the PCL-R-2 correctly identifies personality traits and behaviors that identify the construct he has termed ”psychopathy” • The PCL-R-2 is now a widely used instruments in criminal populations and is frequently used in criminal settings to identify traits and behaviors of the construct of psychopathy • Psychopathy is not a diagnostic disorder in any version of the DSM • The construct of psychopathy should not be confused with the diagnosis of ASPD

11. Psychopathy vs. aspd • In practice, clinicians and other professionals often confuse psychopathy with ASPD and vice versa; however, defining traits, criteria, and criminal behavior for each conceptualized syndrome have substantial differences (APA, 2013; Hare et al., 2000; riser & Kosson, 2013) • Riser and Kosson (2013) have found that individuals identified with psychopathy or psychopathy with a comorbid diagnosis of ASPD were characterized by both an increase in severity and volume of criminal behavior compared to those with ASPD alone • Identified notably different cognitive processing anomalies for individuals with psychopathy compared to those diagnosed with ASPD alone • Between 50% and 80% of prisoners meet criteria for ASPD, whereas only approximately 15% are expected to have psychopathy (Ogloff et al., 2006) • Ogloff et al. (2016) indicated that of the 15% over 65% of inmates high in psychopathic traits were also diagnosed with ASPD, while only 5.5% of those diagnosed with ASPD were found to have a high number of psychopathic traits • Clearly, the construct of psychopathy as defined by Dr. Hare is different than the DSM-5 diagnosis of ASPD

12. Convergence of neuroscience and epidemiology • Bowlby and Ainsworth and Attachment Theory: • Difficulties experienced in adulthood originate from real-life experiences during childhood and adolescence • Neurobiological findings: • Exposure to substantial stressors during childhood and adolescence when the brain is still developing can cause long term neurobiological alterations in multiple areas of the brain including the amygdala, hippocampus, and prefrontal cortex • Such alterations effect the neurochemical systems that regulate cortisol and norepinephrine, which are critical to manage stress response, as well as several other systems that regulate neurotransmitters shown to affect mood, impulsivity, decision-making, and overall psychological functioning

13. Emotional abuse • Physical abuse • Sexual abuse  • Emotional neglect • Physical neglect  • Family violence  • Household substance abuse   • Household mental illness  • Parental separation, death, abandonment, divorce  • Incarceration of household member • Experiences during the first 18 years of life have dramatic effects on not only personality development but also on the development of the brain and an individual’s overall health and quality of life (Anda et al., 2006; Felitti et al., 1998) Adverse Childhood Experiences

14. Adverse Childhood Experiences • Dr. Vincent Felitti and the accidental ACE study at the Kaiser Permanente Obesity Clinic in cooperation with the CDC • “Instead of asking, “How old were you when you were first sexually active,” I asked, “How much did you weigh when you were first sexually active?’ The patient, a woman, answered, ‘Forty pounds.’” • He didn’t understand what he was hearing. He misspoke the question again. She gave the same answer, burst into tears and added, “It was when I was four years old, with my father.”

15. Original ACE studies • Felitti et al. (1998) and Anda et al. (2006) identified a dose-response (as the # of ACEs increases so do the incidence of each outcomes) relationship between ACEs and 7 of top the 10 causes of death, and many other outcomes— • mental health disturbances • somatic disturbances • severe obesity, substance abuse • memory impairment • sexual activity and satisfaction • perceived stress • anger control • risk of intimate partner violence • ischemic heart disease • Cancer • chronic bronchitis or emphysema • chronic lung disease • liver disease • history of hepatitis or jaundice • skeletal fractures • poor self-rated health

16. Subsequent ACE studies • Researchers have since identified a dose-response (as the # of ACEs increases so do the incidence of each outcomes) relationship between ACEs and— • self-reported sleep disturbance • prevalence of tobacco smoking • diabetes mellitus • obesity • hypertension • coronary heart disease • drug or alcohol issues • receive a mental health diagnosis

17. Aces in Arizona 64% of Arizonans experienced at least 1 ACE

18. Aces in arizona

19. Intersection of criminal behavior and mental health: incarceration Part 1 • Of the more than 10.2 million adults held in penal institutions globally 2.24 million are incarcerated in the U.S. • Which constitutes not only the highest total number of prisoners but also the highest proportion of prisoners to the general population (716 per 100,000) of any country in the world • E.g., the incarceration rates in China (124 to 172 per 100,000) and Iran (284 per 100,000) pale in comparison to the U.S. (Travis, Western, & Redburn, 2014) • Only North Korea, a country internationally criticized and sanctioned by the U.S. for human rights abuses (Cohen, 2016; Gershman, 2016), is considered comparable (estimated 600 to 800 per 100,000) but reliable statistics are difficult if not impossible to corroborate (Travis et al., 2014)

20. Intersection of criminal behavior and mental health: incarceration Part 2 • The most recent study by the Bureau of Justice Statistics on the prevalence rates of mental illness found that an estimated 56 percent (n=705,600) of state prisoners, 45 percent (n=78,000) of federal prisoners, and 64 percent (n=479,000) of jail inmates had a mental health problem (James & Glaze, 2006) • According to Steadman et al. (2009), U.S. prevalence rates for serious mental illness amongst inmates were approximately 14.5 percent for males and 31.0 percent for females • U.S. Department of Justice statistics indicate that, according to data collected from 2007 to 2009, approximately 58% of U.S. state prisoners and 63% of sentenced jail inmates met criteria for either a substance use or dependence disorder (Bronson et al., 2017)

21. Arizona: incarceration and mental health • Nguyen and Davis (2017) reviewed several national surveys and determined that the prevalence rate of mental illness in Arizona was 18.59% for adults and 13.23% for youth • Findings indicated that Arizona ranked 50th (out of 51; the District of Columbia was included) in the U.S. for access to mental healthcare for those with mental illness (the ratio of community need to service availability) (Nguyen & Davis, 2017) • This finding is particularly concerning when one considers that Arizona has the 6th highest number of individuals incarcerated (593) per 100,000 state residents (Nguyen & Davis, 2017)

22. Emotional abuse • Physical abuse • Sexual abuse  • Emotional neglect • Physical neglect  • Family violence  • Household substance abuse   • Household mental illness  • Parental separation, death, abandonment, divorce  • Incarceration of household member Trauma, ACES, and criminal offending

23. Childhood Trauma and Criminal Behavior amongst Forensic Populations • Childhood maltreatment was significantly associated with both criminal thinking styles and adult criminal behavior (Cuadra et al., 2014) • Psychiatric conditions in the family, parental alcoholism, and parental divorce were correlated with childhood maltreatment (Sergentanis et al., 2014) • Childhood maltreatment was associated with increased aggression, illicit substance use, psychiatric conditions, smoking, impulsivity and alcohol abuse • In a forensic inpatient sample, the higher the ACE score, the greater the risk of being diagnosed with a mental disorder (Rytila et al., 2014) • Shin et al. (2016) discovered: • Emotional abuse was associated with urgency, a trait of impulsivity, which increased the likelihood of committing a property or fraud offense • Lack of premeditation and impulsivity, when combined with childhood neglect, substantially increased the likelihood of committing a property crime • Physical abuse substantially increased the likelihood of committing every type of crime examined

24. ACEs and juvenile Criminal Offending • Baglivio et al. (2015) examined 64,329 juvenile offenders and discovered: • The higher the number of ACEs, the younger the age of onset of criminal offenses and the greater likelihood of any childhood or adolescent arrest • 30% of youth with criminal behavior as early as 7 years of age (“early onset”) had 5 or more ACEs and an average of 17.8 arrests • The more ACEs one is exposed to the more likely he/she will have chronic styles of offending (or increase the frequency of offenses) • Fox et al. (2015) examined 22,575 offenders and discovered: • The differences between Serious, Violent, and Chronic (SVC) and One and Done (O & D) offenders were substantial enough to distinguish between SVC and O&D offenders by merely examining a juvenile’s total number of ACEs • Each ACE experienced increased the risk of becoming an SVC offender by more than 35%

25. Emotional abuse • Physical abuse • Sexual abuse  • Emotional neglect • Physical neglect  • Family violence  • Household substance abuse   • Household mental illness  • Parental separation, death, abandonment, divorce  • Incarceration of household member • Foster Care Placement • Environmental Violence • Peer/Sibling Bullying Current study Future Adult Outcomes: Severe and/or Chronic Offending Pervasive and/or Severe Mental Illness Antisocial Personality Disorder

26. Literature on Additional aces • Finkelhor et al. (2015) examined approximately 2,000 children and found that Results revealed that peer victimization, peer isolation/rejection, and exposure to community violence were additional predictors of mental health symptoms • Villegas et al. (2012) and Rebbe et al. (2017) identified a higher than normal prevalence of adversity and ACEs in large samples of individuals that were placed in foster care • Turney et al. (2017) examined approximately 100,000 U.S. caretakers, of which 1.4% had children exposed to foster care placement, findings included: • Exposure to ACEs among children in foster care was substantially higher than children in the general population • While some of the associations between foster care placement and ACEs were explained by child-, family-, and household-level characteristics, a substantial number of associations were not explained, which suggested a direct relationship between the experience of foster care and future maladaptive outcomes • Children in foster care were more likely to be exposed to ACEs (with the exception of parental death, which was similarly experienced across child categories) than children in poverty and children in nearly all types of complex family structures (e.g., children with single mothers, homeless children, and children living without their parents without state intervention) • In 2009, the WHO and the CDC met in Geneva, Switzerland to discuss the implications of ACEs and recommended expanding the list to include criminality and organized violence, witnessing criminal and collective violence in the community, exposure to bullying, other forms of peer-to-peer violence, and sibling physical and emotional violence (Anda, Butchart, Felitti & Brown, 2010).

27. Current study: sample • The sample (N = 215) primarily was Caucasian (60%) and male (75.8%), with an average age at evaluation of 35 and average of 13 years of education • This study evaluated the impact of cumulative childhood stress (ACEs) on a cohort of 215 adults referred for psychological evaluation due to crimino-legal or Department of Child Safety (DCS) involvement in Arizona • In total, 797 case files were examined and 582 were excluded, resulting in a final sample of 215 case files

28. Current sample vs. U.S. Census bureau Arizona General population

29. Sample differences from general population • By contrast, the demographics of the current sample consisted of: • More individuals identified as Black (12%) • Substantially less female (24%), which is to be expected in forensic populations • Substantially less Hispanic subjects (15%) • Similar rates of White (60%) and Indigenous or Asian (10%) subjects

30. Current sample vs. Arizona State/Federal Correction authorities

31. Sample differences from Arizona Corrections Population • The sample consisted of more White (60%), Indigenous or Asian (10%), and female (24%) persons • Less Hispanic (15%) and Black (12%) • These differences, though relatively small, are likely due to sample size and inherent differences in the current sample, as it did not exclusively include incarcerated individuals alone but also those involved with DCS and individuals in the midst of criminal litigation whose legal outcomes may not have ultimately resulted in incarceration • The most striking difference is evident in the current sample’s proportion of Hispanic or Latino individuals (15%), which is less than half of the incarcerated population in Arizona (40%) • This suggests that the Latino/Hispanic population is under represented in the current sample, and findings specific to this group should be interpreted with caution • The substantial difference may be related to attorney/judge bias • Fewer financial resources amongst Latino/Hispanic individuals as evaluations not funded by the public defender’s office or the Arizona court system were funded at the personal expense of those being evaluated • Lastly, and perhaps most significantly, individuals evaluated in the archival files were English speaking only, which likely explains a significant proportion of the Hispanic/Latino population disparity

32. Sample differences Comparing prevalence of aces • Such findings suggest that exposure to ACEs increases the risk that individuals will become involved with DCS investigation and/or serious criminal offending as adults

33. Summary of Findings adult criminal behavior (ACB) • Individuals identified with severe or chronic adult criminal behavior (ACB) averaged more than twice as many ACEs (2.8 to 6.7) as those with neither severe nor chronic offending • The strongest model for predicting chronic or severe ACB included the six ACE items of household mental illness, household substance abuse (the greatest single predictor), physical and emotional neglect, physical abuse, and exposure to environmental violence • Over 65% of severe or chronic offenders were exposed to emotional abuse (unrealistic standards), physical abuse, household substance abuse, and parental loss (death, abandonment, separation/divorce) • Significant relationships were identified between severe or chronic ACB and each ACE/AdACE item with the exception of bullying, which trended toward significance

34. Summary of Findings adult psychopathology • Individuals identified with pervasive or severe adult mental illness averaged nearly three times as many ACEs (2.3 to 6.5) as those without pervasive or severe mental illness • The strongest predictive factors of pervasive or severe adult mental illness were household mental illness, household substance abuse, physical neglect, emotional abuse, and parental loss (death, abandonment, separation/divorce) • Over 75% of those with pervasive or severe mental illness were exposed to emotional abuse (unrealistic standards), physical abuse, household substance abuse, and parental loss (death, abandonment, separation/divorce) • Significant relationships were identified between severe or chronic adult mental illness and every ACE/AdACE item • Overall, household mental illness, household substance abuse, physical neglect, emotional abuse, and parental loss correctly identified whether or not an individual had been diagnosed with pervasive or severe mental illness in approximately 83% of the total sample, and correctly identified 89% of individuals diagnosed with pervasive or severe mental illness

35. Summary of Findings antisocial personality disorder (ASPD) • Individuals diagnosed with Antisocial Personality Disorder averaged over four times as many ACEs (1.8 to 7.3) as those without ASPD • The strongest predictive factors of an ASPD diagnosis in adulthood were physical neglect, emotional abuse (unrealistic standards), and exposure to environmental violence; physical neglect and emotional abuse were the two greatest predictors overall • Over 75% of individuals with pervasive or severe mental illness were exposed to emotional abuse (unrealistic standards), physical abuse, household substance abuse, and parental loss (death, abandonment, separation/divorce)

36. Summary of Findings increased risk by ace exposure • Individuals with three to four ACE exposures were 2.33 times (133% increased risk) as likely to have developed pervasive or serious mental illness, 1.2 times (20% increased risk) as likely to have been involved in chronic or severe criminal offending, and 0.5 times (50% decreased risk) as likely to have met criteria for Antisocial Personality Disorder (ASPD) • Those exposed to five or more ACEs were 11.5 times (1050% increased risk) as likely to have developed pervasive or serious mental illness, 6 times (500% increased risk) times as likely to have been involved in chronic or severe criminal offending, and 7.5 times (650% increased risk) as likely to have met criteria for ASPD • Individuals exposed to seven or more ACEs were 20.7 times (1970% increased risk) as likely to have been involved in chronic or severe offending. Odds Ratio: Increased Risk

37. Summary of Findings increased risk for adace exposure • Individuals with three to four AdACE exposures were not found to have an increased risk for any of the three outcomes • However, those exposed to five or more AdACEs were 10 times (900% increased risk) as likely to have developed pervasive or serious mental illness, 5.5 times (450% increased risk) times as likely to have been involved in chronic or severe criminal offending, and 5.3 times (430% increased risk) as likely to have met criteria for ASPD • Individuals exposed to seven or more AdACEs were 12 times (1100% increased risk) as likely to have been involved in chronic or severe criminal offending, and 76 times (7500% increased risk) as likely to have developed pervasive or serious mental illness. Individuals exposed to eight or more AdACEs were 27 times (2600% increased risk) as likely to have been involved in chronic or severe offending Odds Ratio: Increased Risk

38. Summary of Findings decreased risk • Conversely, individuals with less than three ACE/AdACEs were 15-19 times less likely to develop Antisocial Personality Disorder • 5-7 times less likely to become severe or chronic criminal offenders, and 4 times less likely to develop pervasive or severe mental illness • Such findings suggest that those with two or fewer ACEs are significantly less likely to experience the most maladaptive criminal behaviors, mental illnesses, and antisocial personality patterns in adulthood

39. Additional ace factors foster care placement • Foster care placement was also among the weakest contributors to predicting each of the outcome measures, which was likely related to the low prevalence (11% of the total sample, N = 215; 10% of the cases examined for ASPD, n = 40) of exposure to foster care within the sample • Potential change to all out-of-home placements • This may be a result of how foster care and group home placement are approached in Arizona, as an examination of individuals in the sample with more significant juvenile criminal involvement suggests they may have circumvented DCS placements for long-term juvenile treatment and correction facilities

40. Additional ace factors bullying • The bullying item would benefit from increased specificity by raising the threshold of the criterion to that of emotional and physical abuse (by hostile, physically violent, berating, and/or belittling peer/siblings) combined with a measure of time (e.g. the majority of at least one school year or more days than not over a month or semester) • This may allow the bullying item to better discriminate between normative social conflict with peers and severe bullying that has long-term deleterious effects • The bullying item was initially designed to be less discriminating in order to accommodate the less detailed descriptions of bullying included in the case files examined in this study • However, perhaps psychologists and mental health evaluators need to more persistently query experiences related to peer-relations during childhood and adolescences • Evaluators may also benefit from specific training and education about the nature of severe bullying and effective methods for inquiry

41. Additional ace factors environmental violence • The addition of the environmental violence item was clearly justified as the statistical analyses examining its contribution to both adult criminal behavior and ASPD were substantial • In fact, exposure to environmental violence was found to be one of the three strongest predictors of ASPD and one of the six strongest predictors of severe or chronic adult criminal behavior • Exposure to environmental violence was, however, less effective at discriminating between individuals based on the nature of their mental illness • Such a difference, along with findings related to antisocial personality patterns and severe or chronic criminal offending, suggests that exposure to environmental violence along with higher levels of cumulative childhood stress can uniquely influence the development of criminality, or that higher levels of cumulative childhood stress without exposure to environmental violence may lead to the development of problematic mental illness

42. Importance for mitigation • Cumulative childhood stress as measured by Adverse Childhood Experiences damages and alters the neuroanatomy of the brain, which is directly related to the systems designed to manage stress, regulate mood, and maintain adaptive personality traits • The dose-response relationship (as the # of ACEs increase so does the occurrence of each outcome) between ACEs and the most maladaptive types of criminal offending (chronic and severe) suggests that each factor is indeed a noteworthy mitigating factor • The ACE score is a tangible, statistically reliable measure of an individual’s mitigating experiences • The dose-response relationship (as the # of ACEs increase so does the occurrence of each outcome) between ACEs and ASPD suggests that exposure to cumulative childhood stress and/or trauma may differentiate ASPD from other syndromes like psychopathy • Challenges theories about the etiology of ASPD, and perhaps its utility as a measure of personality as currently constructed

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