اختلالات فکری و روانی کودکان و نوجوانان: بازتاب حالت هنر، بر روی ساختار و نظریه اتیولوژیک

Purpose There is a growing interest in the identification of psychopathic traits in infancy and adolescence. This effort will enable the development of predictive models of aggressive and violent behavior, in order to intervene effectively both in preventive and therapeutic levels. Several authors have suggested that the presence or absence of psychopathic traits, together with the factors that sustain, maximize or minimize them, can help in the identification of the etiology and developmental trajectories of anti-social individuals. Materials and Methods Meta-narrative review of the child and adolescent psychopathy construct. Results This state-of-the-art review discusses the concept of child and adolescent psychopathy, taking into account historical and conceptual issues. Conclusion Evolutionary Theories can add a major contribution to the understanding of the origins of psychopathic traits.

Psychopathy can be defined as a personality disorder characterized by a set of traits that include interpersonal and affective characteristics (Factor 1 – e.g., manipulation, lack of empathy) and antisocial/social deviance characteristics (Factor 2 – e.g., impulsivity and aggression) (Hare, 2003). Other authors prefer to describe psychopathy as a developmental disorder (Lynam, Caspi, Moffitt, Loeber, & Stouthamer-Loeber, 2007), marked by an emotional hypo-responsiveness, an increased risk of antisocial behavior (Blair & Mitchell, 2009) and an attentional impairment (Vitale et al., 2005). The concept of psychopathy is not new and is recognized in different cultures and historical periods. Psalmists have identified some key characteristics of the disorder, as wickedness, perversity, immoral behavior, pride, vanity, the sense of invulnerability, seduction, manipulation and extreme violence (Cooke, Michie, & Hart, 2006). The same pattern has been identified in the Icelandic Sagas (Hoyersten, 2001), in the Greek Mythology and in several pre-industrial societies (Murphy, 1976). The first clinical descriptions of psychopathy are ascribed to Pinel (1806/1962) and Prichard (1835), which have respectively used words like “manie sans delire” and “moral insanity”. Brutality, emotional coldness, recklessness and insensitive exploitation of others were some of the attributes mentioned. Other authors (Kraeplin, 1904, Partridge, 1930, Rush, 1812 and Schneider, 1950) have also contributed to the development of psychopathy construct. Rush has even postulated that a deeply rooted “moral depravity” was central in the disorder. Schneider defended that these tendencies emerged early in life, being related with a central deficit in emotional sensitiveness. Notwithstanding, the modern conceptualizations of psychopathy derives essentially from Hervey Cleckley's work revealed in his emblematic book “The Mask of Sanity” (1941/1988). The author tried to narrow psychopathy concept (too inclusive at that time) reserving it to exceptional cases. While studying inpatients at a large psychiatric hospital, he set forth 16 specific criteria, mainly focused on interpersonal and affective features, which he considered to be the main characteristics of psychopathic personality. Central to his conception (and origin of the title of his book) is the idea that psychopathy is a severe disorder masked by an external appearance of robust mental health. The work of Cleckley has become an important mark in the study of psychopathy. Cleckley's 16 criteria (1941/1988) have later been grouped by Patrick (2006) in three distinct conceptual categories: positive adjustment; chronic behavioral deviance; and emotional–interpersonal deficits. The psychopathic characteristics can also be grouped into interpersonal, affect, lifestyle and behavioral characteristics (see Table 1) similar to the Hare model (2003). The interpersonal items would most closely align to Patrick's positive adjustment scale. Lifestyle and antisocial transgressions are somewhat combined but could be further parsed by separating failure to have a life plan and fantastic and uninviting behavior sometimes with drink and sometimes without (sensation seeking). Table 1. Categorization of Cleckey's Diagnostic Criteria into the Hare 4 Factor Model for Psychopathy Interpersonal Affect Lyfestyle Behavioral Deviance – Superficial charm and good “intelligence”* – Untruthfulness and insincerity – Pathologic egocentricity and incapacity for love – Absence of delusions and other signs of irrational thinking* – Lack of remorse or shame – General poverty in major affective reactions – Unresponsiveness in general interpersonal relations – Absence of “nervousness” or psychoneurotic manifestations* – Sex life impersonal, trivial, and poorly integrated – Poor judgment and failure to learn by experience – Unreliability – Specific loss of insight – Fantastic and uninviting behavior with drink and sometimes without – Failure to follow any life plan – Suicide rarely carried out* – Inadequately motivated antisocial behavior Note. Asterisked items are those that Patrick (2006) denoted as positive adjustment. Table options Cleckley (1941/1988) defended that antagonistic, aggressive, predatory, revengeful and cruel behaviors were not essential in the conceptualization of psychopathy. Emphasizing this, he presented cases of “successful psychopaths” that have followed careers as doctors, scholars and businessmen; nonetheless most of his case examples described individuals who engaged in some form of moral transgression. Contemporaries of Cleckley who studied prison inmates shared his opinion concerning a probable deficiency in emotional reactivity. However, had different views about the behavior of these persons, describing the criminal psychopaths as cold, violent, antagonist, truculent and predatory individuals (Lindner, 2003 and McCord and McCord, 1964). As a consequence of these conceptual divergences, Patrick, Fowles, and Krueger (2009) have recently come forth with a triadic conceptualization of psychopathy constituted by the components of disinhibition (externalizing component), boldness and meanness. In this model, these prominent and recurrent phenotypic components can be present in different degrees and may be important to understanding psychopathy in its different manifestations: criminal or non-criminal, primary or secondary, stable or aggressive, successful or unsuccessful. According to Patrick (2010), the conceptual differences in psychopathy change according to the emphasis put on boldness (e.g., spirit of adventure, emotional stability), that occurs mainly in inpatient and community samples (Cleckley, 1988 and Lykken, 1995), or on meanness (e.g., predatory exploitativeness, cruelty), that occurs mainly in forensic samples (Hare, 1985). Not all individuals with a pattern of criminal and anti-social behavior and diagnosed with Antisocial Personality Disorder (APD; American Psychiatric Association, 2000) show psychopathic traits (see Skeem, Polaschek, Patrick, & Lilienfeld, 2011 for a review). Hare (1985) underlines that about 90% of psychopathic aggressors meet criteria for APD, but only 25% of the individuals diagnosed with APD are psychopaths. The same proportion (Forth & Bruke, 1998) occurs in younger populations with Conduct Disorder (CD). These discrepancies seem to be associated with the fact that APD and CD overvalue the externalizing/behavior factor of psychopathy, and not that much the affective/interpersonal one (Forth and Bruke, 1998 and Hare, 1985). This way, some authors are still debating the question of the inclusion of antisocial/deviant life style factor as an inherent trait in psychopathy or its product (Cooke and Michie, 2001, Cooke et al., 2007, Salekin et al., 2006 and Skeem and Cooke, 2010). In short, the psychopathy construct is of utmost importance in clinical and forensic contexts, as it seems to be associated with the most early, severe and stable forms of appearance of antisocial behavior, with a greater risk for criminal recidivism and with a low responsiveness to treatment (DeLisi and Piquero, 2011, Hemphill, 2007 and Leistico et al., 2008). Some authors (DeLisi, 2009, Vaughn and DeLisi, 2008 and Vaughn et al., 2008) even defend that psychopathic traits are similar to career criminality and that psychopathy is the unified theory of crime—a single construct capable of linking the dots of antisocial behavior over the life span. Due to the impact of psychopathy upon society, many authors defend the need to deepen research in this field (e.g., DeLisi and Piquero, 2011, Kotler and McMahon, 2005 and Kotler and McMahon, 2010; Skeem et al., 2011). It seems the best way is to prevent and intervene very early in life, but to achieve that it is necessary to study, among others, what may be the early signs, the risk factors, the protective factors and the developmental trajectories of psychopathy. In other words, it is crucial to study the construct in infancy (Lynam, 1996, Lynam et al., 2007, Salekin and Frick, 2005, Salekin and Lynam, 2010a and Salekin and Lynam, 2010b). Here, we will deal with conceptual and historical questions around child and adolescent psychopathy construct. While analyzing the “state of the art” of the construct, we will present the main etiological theories and indicate, from a critical and reflexive point of view, potential investigation paths at the light of Evolutionary Theories. Child and adolescent psychopathy The roots of the child psychopathy concept are based on the study of adult psychopathy (Kotler & McMahon, 2005, 2010), and can be found in the works of Cleckley (1941/1988), Karpman, 1949 and Karpman, 1950, McCord and McCord (1964), Quay, 1964 and Quay, 1965 and Robins, 1966 and Robins, 1978. In the previously quoted book by Cleckley (1941/1988), the author assumed that psychopathy was a disorder with its roots in childhood or adolescence. About a decade later, McCord and McCord (1964), in the book “The psychopathic: An Essay on the Criminal Mind”, stressed the importance of identifying and treating psychopathy in younger populations. During this era, Quay, 1964 and Quay, 1965 attempted to define subtypes for juvenile delinquency, which were even included as diagnostic specifiers for CD in the “Diagnostic and Statistical Manual of Mental Disorders” (DSM-III; APA, 1980). In DSM-III, CD was characterized by a repetitive and persistent pattern of aggressive behavior with two distinctive subtypes: under-socialized aggressive and socialized aggressive. The first subtype referred to a psychopathic category, with failures concerning empathy, attachment and affectivity, being also associated with a greater number of psychopathological dysfunctional indicators and with a worst prognosis (Quay, 1999). However, these designations, avoiding the use of the derogatory term “psychopathy”, ended up by raising some problems including concerns with respect to the etiology and were, thus, withdrawn from posterior editions of DSM (American Psychiatric Association, 1994 and American Psychiatric Association, 2000). Until relatively recently, there were few published works about child psychopathy, and very little attention was given to the possibility of observing psychopathic traits in minors (Salekin and Lynam, 2010a and Salekin and Lynam, 2010b). Forth, Hart, and Hare (1990) became pioneers in studying child psychopathy in young aggressors, adapting Psychopathy Checklist (PCL; Hare, 1991), showing that some adolescents scored in the assessed dimensions. After this study, different authors developed new measurement tools to assess child/adolescent psychopathy (Salekin and Lynam, 2010a and Salekin and Lynam, 2010b). The extension of psychopathy construct to childhood and adolescence is not exempt of controversy. Questions concerning the overrepresentation in these age ranges of some characteristics of the disorder, the etiologic basis, the malleability of personality during development, the heterogeneity of minors with antisocial behavior, the validity and temporal stability of psychopathy, the derogatory character of the word and its implications in legal context, the potential stigmatization of minors, the triggering of iatrogenic factors, among others, have been raised (e.g., Chanen and McCutchenon, 2008, Edens and Vincent, 2008, Murrie et al., 2007, Seagrave and Grisso, 2002 and Silk, 2008). Some authors (Salekin and Lynam, 2010a, Salekin and Lynam, 2010b and Taylor et al., 2007) defend that although child psychopathy is emerging as an important clinical construct, it is of utmost importance to keep in mind all the criticism that may emerge. This will help that the construct is theoretically more and better supported, the assessment tools are more and more improved, and the words child/adolescent psychopathy are never used in a harmful way but always constructively, aiming an early prevention and identification, together with the establishment of adequate treatment and rehabilitation programs (Vitacco and Salekin, in press and Vitacco et al., 2010). Etiological theories Understanding the development basis of psychopathy has been getting a growing interest by researchers, because it's importance in violence prediction, risk assessment and risk management (e.g., DeLisi, 2009 and DeLisi and Piquero, 2011). Although some authors (e.g., Moffitt, 1993) caution that the existence of a certain type of delinquent behavior during childhood and adolescence is perfectly normal, studies have shown that psychopathy seems to be the sole psychiatric condition that significantly increases the risk of reactive and above all proactive aggression, thus clearly exceeding any parameters (Barry et al., 2000, DeLisi, 2009 and Farrington, 2005). The importance of studying children and adolescents with psychopathic traits is mainly based on two motives: first, to approach elementary etiological issues before the appearance of more severe consequences, and second, because there is a minor possibility that those deviant life styles (e.g., substance abuse) would modify/vitiate the same etiological panorama (Viding & Larson, 2010). There are several etiological theories of psychopathy. The perspectives most referred to in literature are: genetics (e.g., Bezdjian et al., 2011 and Viding et al., 2007); neurosciences (e.g., Blair, 2006 and Viding and Jones, 2008); Callous-Unemotional (CU) traits (e.g., Frick, Kimonis, Dandreaux and Farrel, 2003, Kruh et al., 2005 and Munoz and Frick, 2012); personality (e.g., American Psychiatric Association, 2000, Lynam, 2010 and Lynam and Widiger, 2007) and environmental influences (e.g., Frick, Cornell, Barry, Bodin and Dane, 2003 and Gao et al., 2010). Nevertheless, it is important to underline that many authors think that there is no single gene, no sole neurobiological or neurocognitive dysfunction, no single developmental risk that would act in an isolated way in the etiology and developmental route of psychopathy (Viding & Larson, 2010). Genetics perspective Lykken, 1957 and Lykken, 2006 presented the Low Fear Hypothesis, defending that the etiology of primary psychopathy was largely biological and that, in these cases, environment (namely parental styles), would have little influence on the disorder's development. According to this author, only exceptional parental practices would make possible to reverse the biologically determined psychopathic path of a fearless and “hard-to-socialize” child. At present, this conception detains some empirical support, namely in adoption, twin and preliminary molecular genetics studies (Baker et al., 2009, Beaver et al., 2011, Nordstrom et al., 2011, Viding and Larson, 2010 and Waldman and Rhee, 2006). Thus, it seems psychopathic traits reflect heritable and nonshared environmental influences (e.g., differences in education, and in the relationship with family, peers and teachers) during childhood and adolescence (e.g., Bezdjian et al., 2011, Taylor et al., 2003 and Viding et al., 2007). Up to this moment, no influences in what concerns shared environment (e.g., socio-economic status) were detected in the development of psychopathic traits. Research suggests that the same genetic influences are important to explain the covariance between different aspects of psychopathic personality (CU traits and impulsivity-conduct problems) in both males and females (Larsson, Andershed, & Lichtenstein, 2006). Longitudinal studies of twins have shown that the stability of psychopathic traits in childhood and adolescence is substantially influenced by genetic factors (e.g., Ferguson, 2010). All the studies (e.g., Bezdjian et al., 2011 and Viding et al., 2007), conducted until now, document furthermore that a common genetic ascendance contributes to the covariance between psychopathic traits and anti-social behavior. Studies suggest that the early-onset is more heritable for those children with CU traits that, simultaneously, present anti-social behavior. However, there is evidence that the genetic risk probably acts in conjunction with the environmental factors (Nordstrom et al., 2011 and Waldman and Rhee, 2006). That is, although some authors believe that environmental risk factors do not seem to play a central role in the onset psychopathic traits in children, they acknowledge that they can play a determinant part in the development of anti-social behavior in youths with that same predisposition (Blair et al., 2006 and Lynam et al., 2008).