Psychiatric disorders are diagnosed by determining the presence of specific symptoms, mostly without regards for what caused the symptoms. That is, if you have a specific number of symptoms and meet some additional criteria, then by definition, you have the disorder. For the most part, the rest of medicine doesn’t work this way. If you have a strong headache a neurologist won’t simply tell you that you have a brain tumor. The neurologist is interested in examining the origins of the headache (here I purposely avoided using of the word “cause” ) which would then lead to a more accurate diagnosis. In psychiatry we do this significantly less often because psychiatry exclusively uses a descriptive symptom-base approach to defining psychiatric disorders. Although in most cases this approach leads to useful and valid classifications of psychiatric disorders, there is one domain I believe the system fails miserably: attention and behavioral disorders. I will leave the discussion on attention disorders for another day, but today I want to write about behavioral disorders.

There is a psychiatric disorder called Conduct Disorder. This disorder refers to a pervasive pattern of behaviors in which “the basic rights of others or major age-appropriate societal norms or rules are violated“. The symptoms of this disorder may involve bullying, fighting, using weapons to harm others, being cruel to people or animals, stealing, destroying property, fire setting, etc. Under this definition, many if not most kids in the juvenile justice system (especially repeat offenders) would meet the criteria for this psychiatric disorder. Thus, by definition, you could argue that having chronic behavioral problems and engaging in criminal behavior is considered a psychiatric disorder. My problem with this position is that it assumes that kids who engage in these behaviors have true neurocognitive impairments that result in such behaviors. In many cases this is true, but not in all cases. I should note here that I take a commonly, but not always,  accepted view of psychiatric disorders. Regardless of the “cause,” psychiatric disorders involve impairments in neurocognitive processes that impact a persons emotions, cognition, or behaviors. So, do kids diagnosed with Conduct Disorder truly have a psychiatric disorder? That is, do they truly have impairments in neurocognitive processes that impact their behaviors? Some do, but not all.

What is ironic about this issue is that conduct disorder is recognized as a psychiatric disorder but “psychopathy” is not (at least psychopathy is not included in the Diagnostic and Statistical Manual of Mental Disorder). I say ironic because there is mounting evidence that psychopathy involves marked impairments in neurocognitive processes that affect behavior. What is psychopathy? It is a personality construct that refers to extremes in specific personality traits. Notably, people with high levels of psychopathy (there is debate as to whether psychopathy is a categorical – your have it or your don’t – or a continuous construct) have very high callous-unemotional traits, which refer to a persistent lack of empathy, guilt, emotional depth, and concern for others. Interestingly, only a subset of kids diagnosed with Conduct Disorder also have high levels of psychopathy. Those are, in my view, the kids with a true psychiatric disorder because among these kids, it is a true impairment in neurocognitive functioning –an inability to experience empathy or guilt – that contribute to their behavioral problems.

This week I read a study that provided more evidence of cognitive anomalies among kids with psychopathic traits. In the most recent issue of the Journal of Child Psychology and Psychiatry a team from Australia and the London published a study examining eye contact in 92 male children diagnosed with conduct disorder or oppositional defiant disorder.  The children were also assessed on a measure of callous-unemotional traits and were observed interacting with their parents in an unstructured (free play) and structured (discussion of emotional topic) activity.  The kids’ behavior during these task was coded for frequency of reciprocal eye contact with their parents. The researchers were interested in examining whether those kids with high levels of callous-unemotional traits had different patterns of eye contact with their parents than their peers.

The result:

As you can see above, kids with high levels of callus-unemotional traits (dark bars) engaged in significantly less eye contact with their parents than kids with low levels of callus-unemotional traits. What is significant about this finding is that all of the participants had a diagnosis of a behavioral disorder. Yet, only a subset of these kids scored high on a psychopathy construct and this same subset displayed impairment in normative eye contact processes with their parents.  Why is eye contact relevant? The authors stated:

First, impairments in the natural tendency to attend to affective stimuli, long associated with psychopathic traits, occur early in life in naturalistic settings, in this case, as impairments in making eye contact during free and emotionfocused discussions with attachment figures. Second, the results are consistent with Blair’s idea that psychopathy is in part due to a failure of the violence inhibition mechanism such that a failure to notice distress cues disrupts the potential of such cues to inhibit aggressive behaviour and more  generally, to be internalised as aversive stimuli that effectively promote the development of moral conscience (Blair, 1995). Third, the impairment in eye contact is likely to be a mechanism that helps explain why children with high CU traits are less responsive to quality of parenting (Hawes & Dadds, 2005; Oxford, Cavell, & Hughes, 2003; Viding et al., 2005; Wootton et al., 1997), and fail to develop normal levels of affective empathy (Blair, 2008; Dadds et al., 2009).

In conclusion, this study provided more evidence that a subset of kids diagnosed with conduct disorders display features of psychopathy and impairment in social-cognitive processes (eye contact) that may contribute to their behavioral difficulties.

The reference: Dadds, M., Jambrak, J., Pasalich, D., Hawes, D., & Brennan, J. (2010). Impaired attention to the eyes of attachment figures and the developmental origins of psychopathy Journal of Child Psychology and Psychiatry DOI: 10.1111/j.1469-7610.2010.02323.xResearchBlogging.org

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7 Responses to Child Psychopaths? Poor eye contact and thoughts on psychiatric disorders.

  1. Bette says:

    Very interesting. Tomorrow I am attending a seminar on personality disorders, and I am printing this out to bring a copy to the doctor giving the lecture.

  2. Mary says:

    Okay I understand the whole conduct disorder I get. My son has it. My question is what canbe done to help it. Other than psychotherapy is there anything else.

    My son has learned to fake empathy and guilt. Which is worse because now no one takes my pleas to help him as serious. At 11yrs old I just recently had the police here because he pulled a knife on some kids at our local park. He sat real quiet while they were here. With pleas of being sorry and knowing it was wrong.

    As soon as they left they were idiots; didn’t know what they were talking about. The kids were teasing him and deserved it. ????????????? How do I save him a future of trouble.??? Help if you can please.

    Thank you
    Mary

  3. [...] Child Psychopaths? Poor eye contact and thoughts on psychiatric disorders. (child-psych.org) [...]

  4. chantelle says:

    my son is 17 now and i have suffered years of hell because of my son he has 250 criminal charges some petty some more serious he has been violent towards me almost breaking my cheekbone with one punch when he was 11 years of age he has kicked me took knives to me thrown stones at me in front of his friends stole from me bullied me stole my sisters car harasses his granmother and auntie for money they are to sacred to say no he was put in secure units where he caused thousands of pounds of damage through total anger treats certain friends like his slaves as if he is superior to them treats me like slave also some of the things he has done i find quite disturbing i can only remember one occasion when he showed care for me other than that nothing he has no memory of his childhood nothing seems to affect him he may feel alittle guilt or show a bit of emotion but it never lasts i tried everything to get him help since he was 18 months old i knew ther was something not quite right he was finally diagnosed with oppositional defiance disorder but was told there was no treatment for it whilst in secure unit he was twice found with ligatures around his neck and also self harmed again nothing was done at present hes is in a young adult prison and he is finally agreeingto get help . i must mention that his father my ex partner is a typical psychopath myself and my son also suffered years of physical and extreme emotioanal abuse i finished with him after 25 years a year ago i am getting lots psychological therapy to repair the damage that has ben done . i love my son very much and live in hope that he is not like his father because i would have to face up to the fact that my son is an empty shell like his father i truly hope that he can be fixed . my advice to any parent who has a child like mine should get intervention as early as possible and dont give up as it could save a lot of heartache and pain a mother knows her own child more than anyone so if you think something isnt quite right then usually it isnt

  5. renee says:

    chantelle i know what your talking about. i have a 16 year old son who first was adhd with ODD and always trouble in school. His father was abusive and i left after 21 years. Damaged and trying to put my life together. Over a year ago his dad murdered my little girl who was disabled and then himself. My son was always aggressive and cried many tears. But since our tragedy its gone to a new level. Had so many therapists, programs but had to do an out of control petition with the courts and social services became involved. His behavior went from aggressive to controlling and words cant express the fear for me and his little brother. Time spent the jail, now he is at a treatment facility with the state taking custody. Now the facility tells me he faked it for awhile but were seeing the real personality and telling me how truely dangerous he is with sociopath tendencies. My mind cannot take anymore and i dont know whats going to happen for him, any relationship we have had is very damaged. He feels nothing and it breaks my heart. I guess i was hoping for a magic pill but in reality there is nothing. Ive started therapy for me but fear for myself, my family, for him, and for society in the future.

  6. V. says:

    My teen grandson does not make eye contact, and once had a horrible look come into his eyes when I said something he didn’t like. He’s in quite a bit of trouble with juvie so maybe he’ll finally get more help. I’ve been unable to really get doctors to listen. He’s lied, made up wild tales, stolen from everyone, tried to get small kids to steal from him, set a fire at school, and tries to blame others and make himself the victim. He has ADD and that is usually all doctors will look at. He does have empathy but I’m not sure he’s really ever truly sorry for stealing from people or lying.

  7. Ettina says:

    I’ve started a yahoo group for parents of kids with callous-unemotional traits. If you’re interested in joining, here is the link:
    http://groups.yahoo.com/group/callousunemotional/

    Also, it can’t be lack of eye contact that does it, because autistic kids have been consistently shown to be quite distinct from psychopaths (they care about others even though they don’t understand them) and autistic kids make even less eye contact than this.

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