Persistent violent offending: what do we know?

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Summary

Summary A great deal is known aboutA great deal is known about men who display a stable pattern of men who display a stable pattern of antisocial behaviour since childhood.

antisocial behaviour since childhood.

However, more research is needed to However, more research is needed to identify subtypes within this population so identify subtypes within this population so as to further understanding of the causal as to further understanding of the causal processes that initiate and maintain violent processes that initiate and maintain violent behaviours and to identify interventions behaviours and to identify interventions that specifically target the deficits that specifically target the deficits presented by each subtype.Evidence- presented by each subtype. Evidence- based practice means not only using based practice means not only using treatments proven to be effective but also treatments proven to be effective but also basing conceptualisations of disorders on basing conceptualisations of disorders on scientific evidence.

scientific evidence.

Declaration of interest

Declaration of interest None.None.

We know that many more men than We know that many more men than women become persistent violent offenders women become persistent violent offenders and that a very small group, less than 5%

and that a very small group, less than 5%

of the male population, commit between of the male population, commit between 50% and 70% of all the violent crimes 50% and 70% of all the violent crimes (Moffitt, 1993; Hodgins, 1994). These (Moffitt, 1993; Hodgins, 1994). These men fulfil criteria for diagnoses of conduct men fulfil criteria for diagnoses of conduct disorder before 10 years of age, antisocial disorder before 10 years of age, antisocial personality disorder and psychopathy personality disorder and psychopathy (according to the Psychopathy Checklist–

(according to the Psychopathy Checklist–

Revised (PCL–R); Hare, 1991) in adulthood, Revised (PCL–R); Hare, 1991) in adulthood, and have been labelled as life course persis- and have been labelled as life course persistent offenders. This population, however, is tent offenders. This population, however, is heterogeneous. Identifying the distinct sub- heterogeneous. Identifying the distinct subgroups is essential to unravel the complex groups is essential to unravel the complex and dynamic interactions of biological, psy- and dynamic interactions of biological, psychological and social factors that initiate chological and social factors that initiate and maintain the violent behaviour over the and maintain the violent behaviour over the life span and to establish interventions that life span and to establish interventions that address the specific deficits characterising address the specific deficits characterising each subgroup.

each subgroup.

SUBGROUPS SUBGROUPS

OF PERSISTENT VIOLENT OF PERSISTENT VIOLENT OFFENDERS

OFFENDERS

Within the population of persistent violent Within the population of persistent violent offenders with a stable pattern of antisocial offenders with a stable pattern of antisocial

behaviour since childhood, evidence sug- behaviour since childhood, evidence suggests that there are at least three subgroups gests that there are at least three subgroups with distinct aetiologies and response to with distinct aetiologies and response to treatments. This population first divides in treatments. This population first divides in half based on the presence or absence of co- half based on the presence or absence of comorbid anxiety disorders (Sareen morbid anxiety disorders (Sareen et alet al,, 2004). This evidence from adults is consis- 2004). This evidence from adults is consis- tent with developmental studies of young tent with developmental studies of young children showing that among those with children showing that among those with early-onset conduct problems, one sub- early-onset conduct problems, one subgroup displays high levels of internalising group displays high levels of internalising problems and another does not (Gilliom problems and another does not (Gilliom

& Shaw, 2004). The non-anxious half of

& Shaw, 2004). The non-anxious half of this population contains a subgroup who this population contains a subgroup who present the syndrome of psychopathy as present the syndrome of psychopathy as diagnosed by the PCL–R, which requires diagnosed by the PCL–R, which requires full-blown expression of the traits of arro- full-blown expression of the traits of arro- gant and deceitful interpersonal behaviour gant and deceitful interpersonal behaviour and deficient affective experience (Cooke and deficient affective experience (Cooke

& Michie, 2001) and a much larger group

& Michie, 2001) and a much larger group who do not meet the diagnostic cut-off for who do not meet the diagnostic cut-off for psychopathy, but who obtain higher scores psychopathy, but who obtain higher scores on the traits than men in the general popu- on the traits than men in the general population. By contrast, the highly anxious lation. By contrast, the highly anxious males with antisocial personality disorder males with antisocial personality disorder or conduct disorder present a distinctively or conduct disorder present a distinctively different set of traits.

different set of traits.

During the past 25 years, evidence has During the past 25 years, evidence has accumulated that men within this popu- accumulated that men within this population with psychopathy diagnosed accord- lation with psychopathy diagnosed according to PCL–R differ markedly from the ing to PCL–R differ markedly from the others. They commit more violent offences, others. They commit more violent offences, engage in both instrumental and reactive engage in both instrumental and reactive aggression and more quickly reoffend when aggression and more quickly reoffend when released. They display a profound emo- released. They display a profound emotional dysfunction characterised by im- tional dysfunction characterised by im- paired recognition of fear and sadness in paired recognition of fear and sadness in faces and voices, low levels of stress reactiv- faces and voices, low levels of stress reactivity indexed by heart rate, skin conductance ity indexed by heart rate, skin conductance and cortisol, and a cognitive style domi- and cortisol, and a cognitive style domi- nated by reward and a failure to recognise nated by reward and a failure to recognise punishment. Performance on IQ and stand- punishment. Performance on IQ and stand- ard neuropsychological tests is within ard neuropsychological tests is within normal limits (Patrick, 2006).

normal limits (Patrick, 2006).

Among children with early-onset con- Among children with early-onset conduct disorder, there is a subgroup with duct disorder, there is a subgroup with stable, callous–unemotional traits that are stable, callous–unemotional traits that are thought to represent the antecedents of thought to represent the antecedents of

the psychopathic traits. There are as yet the psychopathic traits. There are as yet no studies that have followed such children no studies that have followed such children into adulthood, but the available evidence into adulthood, but the available evidence suggests that boys who present both con- suggests that boys who present both conduct disorder and callous–unemotional duct disorder and callous–unemotional traits share many features with adult traits share many features with adult psychopathy

psychopathy. Compared with boys with. Compared with boys with conduct disorder alone, boys with both conduct disorder alone, boys with both conduct disorder and such traits present conduct disorder and such traits present more severe conduct problems, more ag- more severe conduct problems, more aggressive behaviour and violent crimes at gressive behaviour and violent crimes at an earlier age. They demonstrate a prefer- an earlier age. They demonstrate a prefer- ence for risky behaviours that are novel ence for risky behaviours that are novel and exciting to them, less reactivity to and exciting to them, less reactivity to threatening and emotionally distressing sti- threatening and emotionally distressing stimuli and a muted cortisol stress response.

muli and a muted cortisol stress response.

They show less ability to recognise sadness They show less ability to recognise sadness in faces and vocalisations and are more im- in faces and vocalisations and are more im- paired on tests of moral reasoning and paired on tests of moral reasoning and empathy. In addition, these boys have diffi- empathy. In addition, these boys have difficulty changing behaviours that are initially culty changing behaviours that are initially rewarded and subsequently punished and rewarded and subsequently punished and emphasise the positive consequences of emphasise the positive consequences of aggressive behaviour but fail to appreciate aggressive behaviour but fail to appreciate the negative consequences. Not surprisingly the negative consequences. Not surprisingly given these characteristics, the boys with both given these characteristics, the boys with both conduct disorder and callous–unemotional conduct disorder and callous–unemotional traits are less responsive to parenting prac- traits are less responsive to parenting practices and most particularly to punishment.

tices and most particularly to punishment.

In addition to the emotional deficits, chil- In addition to the emotional deficits, children with callous–unemotional traits also dren with callous–unemotional traits also display cognitive abnormalities similar to display cognitive abnormalities similar to those observed among adult men with psy- those observed among adult men with psychopathy, and have higher IQ scores than chopathy, and have higher IQ scores than other boys with conduct disorder (Blair, other boys with conduct disorder (Blair, 2003; Frick & Marsee, 2006).

2003; Frick & Marsee, 2006).

Boys with conduct problems who do Boys with conduct problems who do not present callous–unemotional traits dis- not present callous–unemotional traits display aggressive behaviour that is emotion- play aggressive behaviour that is emotionally charged in response to provocations ally charged in response to provocations that may be real or result from their ten- that may be real or result from their tendency to perceive hostility in others, even dency to perceive hostility in others, even in neutral faces (Dadds

in neutral faces (Dadds et alet al, 2006). These, 2006). These children report emotional distress, are more children report emotional distress, are more reactive to distress and especially to nega- reactive to distress and especially to negative emotional stimuli. They are, however, tive emotional stimuli. They are, however, responsive to good parenting practices and responsive to good parenting practices and benefit when their parents complete parent benefit when their parents complete parent training programmes (Hawes & Dadds, training programmes (Hawes & Dadds, 2005). These boys present high levels of im- 2005). These boys present high levels of im- pulsivity, a tendency towards anger and pulsivity, a tendency towards anger and like children with anxiety disorders have like children with anxiety disorders have lower than average verbal abilities (Frick lower than average verbal abilities (Frick

& Marsee, 2006).

The place of attention-deficit hyper- The place of attention-deficit hyperactivity disorder (ADHD) in persistent vio- activity disorder (ADHD) in persistent violent offending and in the characterisation of lent offending and in the characterisation of the proposed subgroups remains unclear the proposed subgroups remains unclear (Waschbusch, 2002). This is often comorbid (Waschbusch, 2002). This is often comorbid with conduct disorder and the combination with conduct disorder and the combination

s1 2 s1 2

B R I T I S H J O U R N A L O F P S YC H I AT RY

B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 7 ) , 1 9 0 ( s u p p l . 4 9 ) , s 1 2 ^ s 1 4 . d o i : 1 0 . 11 9 2 / b j p . 1 9 0 . 5 . s 1 2( 2 0 0 7 ) , 1 9 0 ( s u p p l . 4 9 ) , s 1 2 ^ s 1 4 . d o i : 1 0 . 11 9 2 / b j p . 1 9 0 . 5 . s 1 2

E D I T O R I A L E D I T O R I A L

Persistent violent offending: what do we know?

SHEILAGH HODGINS SHEILAGH HODGINS

AUTHOR’S PROOF

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P E R S I S T E N T V I O L E N T OF F E N D IN G P E R S I S T E N T V I O L E N T O F F E N D I N G

is predictive of criminality in adulthood.

Among boys with conduct disorder and Among boys with conduct disorder and ADHD, it is callous–unemotional traits ADHD, it is callous–unemotional traits and not ADHD symptoms that are asso- and not ADHD symptoms that are associated with aggression and delinquency.

ciated with aggression and delinquency.

Further, boys with such traits without Further, boys with such traits without ADHD have been shown to have the high- ADHD have been shown to have the high- est rates of aggressive behaviour and delin- est rates of aggressive behaviour and delinquency (Frick & Marsee, 2006). Recent quency (Frick & Marsee, 2006). Recent evidence demonstrates that both the geno- evidence demonstrates that both the genotype and the phenotype of ADHD are het- type and the phenotype of ADHD are heterogeneous, and that IQ mediates, at least erogeneous, and that IQ mediates, at least in part, psychosocial functioning, including in part, psychosocial functioning, including violent offending, in adulthood (Mill violent offending, in adulthood (Mill et alet al,, 2006). Boys with conduct disorder and 2006). Boys with conduct disorder and ADHD obtain lower IQ scores and are ADHD obtain lower IQ scores and are more impulsive than boys with only con- more impulsive than boys with only conduct disorder. Inattention precedes the on- duct disorder. Inattention precedes the onset of conduct disorder, allowing for the set of conduct disorder, allowing for the possibility that early intervention could possibility that early intervention could interrupt the development of conduct disor- interrupt the development of conduct disorder (Simonoff, 2000; Waschbusch, 2002).

der (Simonoff, 2000; Waschbusch, 2002).

Available evidence suggests that the Available evidence suggests that the aetiology in the three subgroups of males aetiology in the three subgroups of males with early-onset stable antisocial behaviour with early-onset stable antisocial behaviour differs. A meta-analysis of twin and family differs. A meta-analysis of twin and family studies reported a modest genetic contribu- studies reported a modest genetic contribu- tion (0.41 heritability) to the development tion (0.41 heritability) to the development of early-onset and stable antisocial behav- of early-onset and stable antisocial behaviour, including substance misuse (Rhee &

iour, including substance misuse (Rhee &

Waldman, 2002), but depending on the Waldman, 2002), but depending on the definition of the phenotype other studies definition of the phenotype other studies report much higher heritability coefficients report much higher heritability coefficients (Young

(Young et alet al, 2000). Recent evidence sug-, 2000). Recent evidence suggests that callous–unemotional traits are gests that callous–unemotional traits are also heritable. For example, a recent study also heritable. For example, a recent study of young twins in the UK has shown that of young twins in the UK has shown that the combination of conduct problems and the combination of conduct problems and callous–unemotional traits is much more callous–unemotional traits is much more heritable (heritability coefficient 0.81) than heritable (heritability coefficient 0.81) than conduct problems alone (heritability coeffi- conduct problems alone (heritability coefficient 0.30) (Viding

cient 0.30) (Viding et alet al, 2005). This is con-, 2005). This is con- sistent with studies of older participants sistent with studies of older participants showing high heritability for psychopathic showing high heritability for psychopathic traits (Blonigen

traits (Blonigen et alet al, 2003; Taylor, 2003; Taylor et alet al,, 2003; Larsson

2003; Larsson et alet al, 2006). These results in-, 2006). These results in- dicate that from conception onwards indi- dicate that from conception onwards individuals who display early-onset stable viduals who display early-onset stable antisocial behaviour differ from the rest of antisocial behaviour differ from the rest of the population and that the subgroup who the population and that the subgroup who will develop callous–unemotional traits will develop callous–unemotional traits differ from the others. Genes modify the differ from the others. Genes modify the individual’s interaction with their environ- individual’s interaction with their environ- ment, hence each of the subtypes would ment, hence each of the subtypes would be reacting to and selecting environments be reacting to and selecting environments differently from conception onwards.

differently from conception onwards.

Interestingly, this would mean that the Interestingly, this would mean that the subgroups would react differently during subgroups would react differently during the prenatal period when individual the prenatal period when individual thresholds for stress reactivity of the thresholds for stress reactivity of the

hypothalamic–pituitary–adrenal axis are hypothalamic–pituitary–adrenal axis are set (Susman, 2006). This could be one of set (Susman, 2006). This could be one of the reasons why one sub-group displays the reasons why one sub-group displays high anxiety levels and another presents high anxiety levels and another presents abnormally low levels.

abnormally low levels.

As is hypothesised for other complex As is hypothesised for other complex disorders, each of the genes involved in disorders, each of the genes involved in antisocial and aggressive behaviour may in- antisocial and aggressive behaviour may in- teract with a specific environmental factor teract with a specific environmental factor to determine outcome. For example, a func- to determine outcome. For example, a functional polymorphism in the promoter of the tional polymorphism in the promoter of the monoamine oxidase A gene had previously monoamine oxidase A gene had previously been associated with persistent aggressive been associated with persistent aggressive behaviour in animals and in one human behaviour in animals and in one human pedigree. In a birth cohort, neither the pedigree. In a birth cohort, neither the low nor high activity allele was associated low nor high activity allele was associated with violent behaviour in adulthood. The with violent behaviour in adulthood. The males in the cohort who carried the low ac- males in the cohort who carried the low activity allele and who experienced physical tivity allele and who experienced physical abuse during childhood were three times abuse during childhood were three times more likely than the men with the same al- more likely than the men with the same allele who had not experienced abuse to pre- lele who had not experienced abuse to present conduct disorder and ten times more sent conduct disorder and ten times more likely to commit violent criminal offences.

likely to commit violent criminal offences.

Physical abuse in the absence of the gene Physical abuse in the absence of the gene did not increase the risk of conduct disorder did not increase the risk of conduct disorder or violent crime (Caspi

or violent crime (Caspi et alet al, 2002). Two, 2002). Two studies have replicated this finding in White studies have replicated this finding in White males (Foley

males (Foley et alet al, 2004; Widom &, 2004; Widom &

Brzustowicz, 2006). Thus, individuals who Brzustowicz, 2006). Thus, individuals who differed in genetic profile reacted differ- differed in genetic profile reacted differently to their environments, and even to a ently to their environments, and even to a severe event such as physical abuse.

severe event such as physical abuse.

IMPLICATIONS IMPLICATIONS OF THE FAILURE OF THE FAILURE

TO IDENTIFY SUBTYPES TO IDENTIFY SUBTYPES The failure to distinguish subtypes within The failure to distinguish subtypes within the population of males who show an the population of males who show an early-onset and stable pattern of antisocial early-onset and stable pattern of antisocial and aggressive behaviour blocks progress and aggressive behaviour blocks progress in research aimed at furthering understand- in research aimed at furthering understanding of persistently violent offenders and in ing of persistently violent offenders and in efforts to identify effective treatments. Con- efforts to identify effective treatments. Con- sider for example, studies using single- sider for example, studies using single- photon emission computed tomography photon emission computed tomography (SPECT), magnetic resonance imaging (SPECT), magnetic resonance imaging (MRI), and functional MRI to investigate (MRI), and functional MRI to investigate brain structure and functioning. These stu- brain structure and functioning. These studies have focused largely on men who met dies have focused largely on men who met criteria for psychopathy. Participants have criteria for psychopathy. Participants have been characterised using different cut-off been characterised using different cut-off scores and different scales, and little atten- scores and different scales, and little attention has been paid to the composition of tion has been paid to the composition of the comparison group. Results have been the comparison group. Results have been inconsistent and difficult to interpret. One inconsistent and difficult to interpret. One reason might be that the comparison group reason might be that the comparison group included offenders with and without included offenders with and without

anxiety disorders. A recent fMRI study anxiety disorders. A recent fMRI study comparing boys with and without conduct comparing boys with and without conduct disorder illustrates the problem. Contrary disorder illustrates the problem. Contrary to the hypothesis, no differences in activity to the hypothesis, no differences in activity in the amygdala were observed when view- in the amygdala were observed when view- ing negative pictures. This absence of a dif- ing negative pictures. This absence of a dif- ference, however, was due to high anxiety ference, however, was due to high anxiety scores among some of the boys with con- scores among some of the boys with conduct disorder. Post hoc analyses showed duct disorder. Post hoc analyses showed that anxiety scores, as would be expected, that anxiety scores, as would be expected, were related to amygdala activation and ag- were related to amygdala activation and aggressive behaviour scores were related to gressive behaviour scores were related to amygdala inactivity (Sterzer

amygdala inactivity (Sterzer et alet al, 2005)., 2005).

These results clearly suggest that a more ac- These results clearly suggest that a more ac- curate description of the subtypes is needed curate description of the subtypes is needed to unravel the aetiology of early-onset to unravel the aetiology of early-onset stable antisocial behaviour.

stable antisocial behaviour.

The failure to characterise subtypes The failure to characterise subtypes within this population may also lead to within this population may also lead to difficulty in interpreting the evaluations of difficulty in interpreting the evaluations of treatment programmes. It has been known treatment programmes. It has been known for a number of years that parent training for a number of years that parent training programmes reduce conduct problems programmes reduce conduct problems among young children (Farmer among young children (Farmer et alet al,, 2002). A recent study showed that children 2002). A recent study showed that children with conduct disorder but without callous–

with conduct disorder but without callous–

unemotional traits benefited most, whereas unemotional traits benefited most, whereas those with such traits only learned when those with such traits only learned when reward was used. Time-out, although an reward was used. Time-out, although an effective intervention for the children with- effective intervention for the children without callous–unemotional traits, failed to out callous–unemotional traits, failed to reduce inappropriate behaviours displayed reduce inappropriate behaviours displayed by the children with such traits (Dadds by the children with such traits (Dadds et al

et al, 2005). Insensitivity to punishment, 2005). Insensitivity to punishment is a key feature of psychopathy and of is a key feature of psychopathy and of children with conduct disorder and children with conduct disorder and callous–unemotional traits, but not of the callous–unemotional traits, but not of the other subgroups (Dadds & Salmon, other subgroups (Dadds & Salmon, 2003). Taking account of the presence or 2003). Taking account of the presence or absence of such characteristics when devel- absence of such characteristics when devel- oping treatment programmes will increase oping treatment programmes will increase their specificity and thereby effectiveness.

their specificity and thereby effectiveness.

Although several offender rehabilita- Although several offender rehabilitation programmes have been shown to be tion programmes have been shown to be as effective as most accepted medical treat- as effective as most accepted medical treatments, there is little evidence about the ments, there is little evidence about the characteristics of offenders who benefit characteristics of offenders who benefit and those that do not (Welsh

and those that do not (Welsh et alet al, 2002)., 2002).

Richer and more complete characterisa- Richer and more complete characterisa- tions of the subtypes of persistent violent tions of the subtypes of persistent violent offenders would lead to the development offenders would lead to the development of treatments that directly target deficits.

of treatments that directly target deficits.

For example, one of the characteristics of For example, one of the characteristics of boys with conduct disorder and callous–

boys with conduct disorder and callous–

unemotional traits and offenders with unemotional traits and offenders with psychopathy is their altered perception of psychopathy is their altered perception of reward and punishment. Both in neuropsy- reward and punishment. Both in neuropsychological tests and in real-life situations, chological tests and in real-life situations, they focus on rewards and ignore punish- they focus on rewards and ignore punish- ments. Consequently, they persistently miss ments. Consequently, they persistently miss

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AUTHOR’S PROOF

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HO D G I N S HO D G IN S

the signal – the punishment – that a behav- the signal – the punishment – that a behaviour is inappropriate. As children, this may iour is inappropriate. As children, this may be one of the key mechanisms that pro- be one of the key mechanisms that pro- motes their antisocial behaviour and that motes their antisocial behaviour and that limits their access to the usual socialising limits their access to the usual socialising experiences such as sports and other com- experiences such as sports and other community activities, and eventually even to munity activities, and eventually even to school. The problem persists into adult- school. The problem persists into adulthood and is present, for example, later in hood and is present, for example, later in life when they are incarcerated and enrolled life when they are incarcerated and enrolled in an offender rehabilitation programme.

in an offender rehabilitation programme.

Many of these programmes include a mod- Many of these programmes include a mod- ule designed to develop problem-solving ule designed to develop problem-solving skills. Problem-solving is divided into four skills. Problem-solving is divided into four steps. Step one involves identifying the steps. Step one involves identifying the problem, step two generating as many problem, step two generating as many responses as possible, step three assessing responses as possible, step three assessing the likely positive and negative conse- the likely positive and negative consequences of each possible response, and the quences of each possible response, and the final step selecting the best response. At final step selecting the best response. At step three, men with psychopathy and step three, men with psychopathy and boys with conduct disorder and callous–

boys with conduct disorder and callous–

unemotional traits would focus on rewards unemotional traits would focus on rewards and be less able than others to identify and be less able than others to identify possible negative outcomes. To help them possible negative outcomes. To help them learn to solve problems would first require learn to solve problems would first require teaching them to identify negative out- teaching them to identify negative outcomes. For the adults, this may be particu- comes. For the adults, this may be particularly difficult as they have had so many larly difficult as they have had so many years without this skill.

years without this skill.

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s1 4 s1 4

AUTHOR’S PROOF AUTHOR’S PROOF

SHEILAGH HODGINS, PhD, Department of Forensic Mental Health Science, Institute of Psychiatry, King’s SHEILAGH HODGINS, PhD, Department of Forensic Mental Health Science, Institute of Psychiatry, King’s College London SE5 8AF, UK. Email: s.hodgins

College London SE5 8AF, UK. Email: s.hodgins@@iop.kcl.ac.ukiop.kcl.ac.uk

(4)

10.1192/bjp.190.5.s12 Access the most recent version at DOI:

2007, 190:s12-s14.

BJP

Sheilagh Hodgins

Persistent violent offending: what do we know?

References

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