Clinical diagnosis of juvenile sociopaths

Tangentially related to: Teens kill a man for fun.

After a bit of googling, it appears that there is disagreement over whether juveniles (under 18) can be clinically diagnosed as APD (aka sociopaths). Does anyone know the reason for this controversy? Can anyone provide an argument one way or the other?

Well, I’m not an expert on the research surrounding anti-social personality disorder. That said, according to the DSM IV:

The diagnostic criteria include “a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years….”

Under the age of 18, children who exhibit these symptoms are diagnosed as suffering from “Conduct Disorder.”

There is a much deeper argument here, concerning the extent to which people really do fall naturally into these categorical groupings. I’d just like to skirt the issue and say that the lines which divide types are constantly contested and open to modification. Hence the controversy, although I don’t know much about it. I would not be surprised to learn that there are significant legal ramifications connected to the question of which disorder one has. Differential diagnosis is much more of an art than a science.

I suspect this is more of a General Question than a Great Debate.

Mr. Svinlesha is correct. Antisocial Personality Disorder (APD), by DSM-IV definition, cannot be applied to children under 18. It is also not exactly correct that APD is “also known as” sociopathy (or psychopathy), although the concepts share similarities.

There are three disorders that are presumed to reflect the development of antisocial behavior over the life span: Oppositional Defiant Disorder, Conduct Disorder and APD. They roughly follow the “rule of thirds”: about 1/3 of those with ODD develop CD and about 1/3 of those with CD develop APD.

Just to clarify something from Mr. S’ post: someone over 18 can still be diagnosed with CD if they meet those criteria and do not meet the criteria for APD, although in practice CD is typically not diagnosed in adults.

I don’t look at it as “controversy,” but there is a recognition that these constructs don’t work perfectly. There is quite a bit of examination of the presence of callous and unemotional features in children, and whether taking such features into account will improve the utility of the diagnosis of CD. Presently, the diagnosis of CD is very much determined by discrete behaviors (runs away, skips school, vandalizes, attacks others), which has the advantage of improving the reliability of the diagnosis (these types of behaviors are easily defined and require less subjective judgment).

On the other hand, there are aspects of some antisocial peope that are less easy to define and require greater subjectivity (e.g. doesn’t seem to feel guilty when he should, acts sneaky, is a smooth talker) which may improve our ability to make predictions about which people will develop poorer outcomes, but which come with a trade off in reliability.

Also, the behaviors of CD are clearly undesirable. However, the behaviors often associated with psychopathy or callous and unemotional behavior, can be positive traits in some circumstances. You would probably want your lawyer or your company’s CEO to be smooth talking and able to manipulate people to some extent.

I remember some years ago seeing a documentary on sociopaths which indicated that research showed that sociopaths had identifiable differences in brain function and that these differences were apparent in early childhood. This site has some interesting information.

Unfortunately we have not in fact identified any neuroanatomical markers of APD or psychopathy. I tried to look at the support cited within the Biology 202 paper you linked to, don’t ask, but unfortunately most of the links were broken (although they seemed to link not to scientific research sites, but things like ABC News).

We have linked some changes in neurotransmitters or hormones such as cortisol to antisocial behavior, but apart from believing that cortisol levels are lower in people who show antisocial behavior, we can only speculate about how this might explain antisocial behavior.

Thank you for correcting a bit of TV “knowledge”.

Mr. Svinlesha, can you be more specific as to the source of your cite? I’ve seen differing quotes supposedly taken from the DSM-IV: some say that APD is “rarely diagnosed” in juveniles, and others that it cannot be. It isn’t clear to me what the standard psychological practice is. I cannot seem to find a current edition online from which to quote.

The reason I put this in GD to try and get at the reason that juveniles are rarely diagnosed as APD (which wikipedia equates to sociopathic disorder). Similar disorders are routinely diagnosed in children, why not this one? I assume that the reasons behind this are controversial and go to some of the questions that came up in the other thread. If the reasons are more mundane, please educate me.

If that’s not enough controversy for GD, add this: Given that some researchers believe that APD may have genetic triggers, if you are diagnosed with APD, should society hold you any less responsible for your actions?

Well, even though I’m not Mr. S, I can tell you that the DSM IV Criterion B of the diagnosis of APD is “B. The individual is at least age 18 years.” If you have a page number or something for the quote that it is “rarely diagnosed” in juveniles, I’ll be happy to check the DSM IV for you. It is possible that another diagnostic framework, such as the ICD-10, does not have an age 18 cutoff; I am not sure about that.

When you say clinical diagnosis, you are indicating a specific construct. It is therefore not equivalent to “sociopathic disorder.” In DSM-IV, there is no such thing as “sociopathic disorder.” Studies of the overlap between APD and psychopathy show that a large proportion of people may meet criteria for APD without meeting criteria for psychopathy, for example.

I’m not sure why you are dissatisfied with the explanation I gave you above, but it really is as simple as that. That is, APD is regarded as the homotypic progression of Conduct Disorder.

Is there any precedent for using genetic risk as a mitigating factor? Why should APD be any different? Genetic risk does not equal predetermination.

No, because people with APD can resist their compulsions to kill or hurt if they try. People with APD know that what they are doing is wrong, which means that someone couldn’t be given a “not guilty by reason of insanity” sentence if there was no other mental affliction involved.

Jeffrey Dahmer had some variant of APD, I believe, and he said during his trial that he was fully aware he was committing evil but “couldn’t” stop. If he had said that killing and eating people gave him the strength to do battle with mighty Xenu (and sincerely believed it), then perhaps you wouldn’t hold him responsible, but he knew the difference between right and wrong, as all people with APD do. He just didn’t care.

And of course, genes don’t determine outcome… this is all predicated on a scenario where someone is actually diagnosed with it.

Sorry, I should have let your post sink in before I replied, Hentor. That makes sense to me. So is Wikipedia wrong to equate APD with “sociopathic disorder?” Is the latter a professional term or pop psychology?

 In my mind, a sociopath (in the pop culture sense) is more than just someone who routinely behaves antisocially, but that seems like all APD is.  If someone with APD knows right from wrong, is capable of acting right, and is diagnosed solely by their bad behavior, aren't they choosing to be/have APD?  I'm clearly missing something.  Does having APD mean that you don't have the normal guilt associated with doing something wrong?  Isn't guilt part of what helps us develop our sense of right and wrong?

Thanks for the thoughful replies. If these questions are all answered somewhere, feel free to just send me the link instead of typing stuff here.

The latter is not a professional term. I really don’t know what it is. The construct of psychopathy is the only other construct related to adult antisocial behavior that is currently given any attention in mental health literature. Callous and unemotional behaviors or features are presently being given attention as potential indicators of antisocial personality features in childhood, but this is a very young branch of research.

APD attempts to serve as a marker for a chronic history of antisocial behavior with roots in adolescence or earlier. There are elements of the DSM IV APD criteria that do move from exclusively behavioral referents, unlike CD symptoms, notably “lack of remorse.” However, in contrast to the construct of psychopathy, APD attempts to rely more on behaviors than personality features. The question is how well these items capture all those people who we think it should (which goes for Oppositional Defiant Disorder and Conduct Disorder).

Guilt is part of the diagnosis (specifically lack of remorse), although someone can meet the criteria for APD without meeting that one criterion. I’m not sure about the issue of choosing to have APD. Volitional control over the entirety of our behaviors doesn’t seem as clear cut as your question might imply. Does a smoker who wishes to quit and can stop any time they like simply choose to continue to smoke? I don’t mean to imply that we know there is some process akin to the addiction of a smoker to be found within APD, I’m just saying that the interplay between indvidual neurobiochemical make-up, personal history and environment probably play upon folks in different ways and in ways that make a dichotomous choose to/don’t choose to explanation somewhat less useful.

I agree. I think that is why personal responsibility so complicated. If it is true that environment/genetics make it easier for people without APD to choose to do good, then, in my mind at least, an individual with APD is slightly less responsible for their actions. I see problems with applying that to a legal system, of course, but I’m curious if others share that intuition.

Everyone has things they want to do or don’t like doing. But even having an addiction to smoking doesn’t “make” you smoke. You’re the one who picks up the ciggaretee and keeps on doing doing it, not the addiction. Most people just plain like the feeling of the cig and fear the pain of withdrawal more than they want to quit, and choose to follow their instinct rather than knowledge. Same with this. The ones that kill make a choice that they like killing more than they wish to obey conventional morality.

It’s too bad, too - in my philosophical system, obediance to a good principle reached through logic when one’s will is not in line with that good principle is at least as laudable as those whose actions follow their good hearts.

I am again reminded of the time, many years ago, when we went on a family trip to Disneyland. As we were trying to make plans about what we should do if we got separated, or lost, my brother angrily cut us off. His plan: “Just don’t get lost!”

… which has nothing to do with this. Genes do not pick up your leg and stomp homeless people to death. Neither does an abnormal brain structure pick up your leg. They *might * make you feel little guilt about doing so or encourage you to, but that’s not my concern, now, is it?