Adolescence: Developmental, Clinical, and School Psychology – Lecture 6 (UNIVERSITY OF AMSTERDAM)

Antisocial behaviour includes lying (1), fighting (2), bullying (3), truancy (4) and stealing (5) and it also occasionally occurs in typically developing children, adolescents and adults. This behaviour is most common in toddlerhood as disruptive behaviour in young children one of the most common problems experienced in the parenting context. It is one of the main reasons for parents to seek help.

The age-antisocial behaviour curve refers to antisocial behaviour becoming more common during adolescence and decreasing in frequency after adolescence. About 70% of the adolescents have ever engaged in antisocial behaviour. Antisocial behaviour is most common during adolescence in the interpersonal sphere and antisocial behaviour also hurts the development of the individual.

The maturity gap refers to a gap between biological and social maturation. This may explain the rise in the age-crime curve during adolescence.

Disruptive behavioural disorders refer to disorders which include problems in the self-control of emotions and behaviours. The problems are manifested in behaviours that violate the rights of others (e.g. aggression; destruction of property) and it brings the individual into significant conflict with societal norms or authority figures.

There are several types of disruptive behavioural disorders:

1. Conduct disorder (CD)
   This characterized by disruptive behaviour and is mainly about behaviour.
2. Oppositional defiant disorder (ODD)
   This is characterized by angry and irritable behaviour and the adolescent being conflict seeking and disobedient. It includes behaviour and emotions.
3. Intermittent explosive disorder
   This is characterized by uncontrolled and disproportional anger and is mainly about emotions.
4. Antisocial personality disorder

There is a continuum between behaviour and emotions with behaviour and emotions in the middle. Oppositional defiant disorder has a prevalence from 1% to 11% and has several characteristics:

1. A pattern of angry/irritable mood
   This includes argumentative/defiant behaviour or vindictiveness for at least six months as characterized by any of the following symptoms from the categories exhibited during interaction with at least one individual who is not a sibling:
   1. Anger
      1. Often losing temper.
      2. Often touchy or easily annoyed.
      3. Often angry and resentful.
   2. Argumentative/defiant behaviour
      
      1. Often arguing with authority figures or adults (i.e. do or have to allergy).
      2. Often actively defies or refuses to comply with requests from authority figures or with rules.
      3. Often deliberately annoys others.
      4. Often blames others for one’s mistakes or misbehaviour (i.e. never one’s fault).
   3. Vindictiveness
      
      1. Has been spiteful or vindictive at least twice in the last six months.
2. Distress
   The disturbance in behaviour is associated with distress in the individual or others in one’s immediate social context or it negatively impacts social, educational, occupational or other important areas of functioning.
3. Alternative explanation
   The behaviours do not exclusively occur during the course of a psychotic, substance use, depressive or bipolar disorder. In addition to this, the criteria for disruptive mood dysregulation disorder must not be met.
4. Severity
   The pervasiveness of the symptoms (i.e. across settings) is an indicator of the severity of the disorder.
   
   1. Mild (i.e. one setting)
   2. Moderate (i.e. two settings)
   3. Severe (i.e. three or more settings).

Conduct disorder has a prevalence of 2% to 10% and there are several diagnostic criteria:

1. Pattern of behaviour
   There is a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated as indicated by the presence of at least three criteria in the past 12 month with at least one in the last six months:
   1. Aggression to people and animals
      1. Bullying, threatening or intimidating others.
      2. Initiating physical fights.
      3. Has used a weapon that can cause serious physical harm.
      4. Has been physically cruel to people.
      5. Has been physically cruel to animals.
      6. Has stolen while confronting a victim (e.g. mugging).
      7. Has forced someone into sexual activity.
   2. Destruction of property
      
      1. Has deliberately engaged in setting fire with the intention of causing serious damage.
      2. Has deliberately destroyed others’ property.
   3. Deceitfulness or theft
      
      1. Has broken into someone else’s house, building or car.
      2. Often lies to obtain goods or favours or to avoid obligations.
      3. Has stolen items of non-trivial value without confronting a victim (e.g. shoplifting).
   4. Serious violations of rules
      
      1. Often stays out at night despite parental prohibitions beginning before 13 years of age.
      2. Has run away from home overnight at least twice or once without returning for a lengthy period.
      3. Often truant form school beginning before 13 years of age.
2. Distress
   The disturbance in behaviour causes clinically significant impairment in social, academic or occupational functioning.
3. Alternative explanation
   The criteria are not met for antisocial personality disorder when the individual is older than 18 years.
4. Onset
   
   1. Childhood-onset type (i.e. one symptom before age 10).
   2. Adolescent-onset type (i.e. no symptoms before age 10).
   3. Unspecified-onset type (i.e. diagnosis but unclear when the first symptom was).
5. Specifics
   A person with conduct disorder is often callous and unemotional. There are limited prosocial emotions (1), a lack of remorse or guilt (2), unconcerned about performance (3) and shallow or deficient affect (4).
6. Severity
   
   1. Mild (i.e. few conduct problems in excess of those required to make the diagnosis and the problems cause minor harm).
   2. Moderate (i.e. number of conduct problems and the effect of those are between those in mild and those in severe).
   3. Severe (i.e. many conduct problems in excess of those required to make the diagnosis present and the problems cause considerable harm to others).

A childhood onset is associated with higher developmental risk and is more often combined with ADHD or other neurodevelopmental disorders. It occurs more often after ODD.

Conduct disorder occurs more often periodically. There are better relationships with peers but they are controversial. In sociometrics, they are often seen both positively and negatively by people.

People with conduct disorder and psychopathic traits recognize emotions equally well as people without conduct disorder but with psychopathic traits. They recognize anger the least well and they are highly accurate in the recognition of disgust, fear and sadness.

The shortage theory states that a deficit in emotion recognition of anger leads to a lack of social inhibition of aggressive behaviour. Anger may be confused with disgust and surprise and can be perceived as social rejection, leading to an interpretation bias. This can lead to more aggression as social rejection is related to aggression. Social rejection leads to shame and this can lead to a confession (i.e. submissive position) or to anger. Due to the interpretation bias of people with conduct disorder, shame leads to blaming the victim and aggression.

According to the arousal theory, there are different pathways to aggressive behaviour:

1. Feelings of grandiosity leads to a stronger sense of shame and this leads to aggressive behaviour.
2. Disgust, shame or insult leads to increased arousal and this leads to more aggressive behaviour.
3. A reduced amygdala activity with fear and distress of others leads to lower arousal and stress and low arousal can make aggression more likely

The arousal theory holds that feelings of grandiosity is associated with a stronger sense of shame and this leads to aggressive behaviour. Next, disgust, shame or insult leads to increased arousal and this also leads to aggressive behaviour.

Intermittent explosive disorder has a prevalence of 2.7%. It is characterized by fast, short, impulsive and disproportional anger outbursts. The outbursts has no warning, no prodromal phase and the duration is less than 30 minutes. It is a reaction to minimal provocation. It is impossible to control, disproportional and impulsive. It has several diagnostic criteria:

1. Behavioural outbursts
   There are recurrent behavioural outbursts representing a failure to control aggressive impulses as manifested by the following:
   1. Verbal aggression or physical aggression toward property, animals or other individuals occurring twice weekly for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not lead to physical injury.
   2. Three behavioural outbursts involving damage or destruction of property and/or physical assault involving physical injury within a 12-month period.
2. Magnitude
   The magnitude of aggressiveness expressed during recurrent outbursts is grossly out of proportion to the provocation or any precipitating psychosocial stressor.
3. Impulsive
   The recurrent aggressive outbursts are not premediated (i.e. impulsive) and do not have a clear goal.
4. Distress
   The recurrent aggressive outbursts cause marked distress or impairment
5. Age
   The chronological age is at least 6 years.

The diagnosis of IED can be made in addition to the diagnosis of ADHD, CD, ODD or ASD when recurrent aggressive outbursts are in excess of those usually seen in those disorders. Antisocial personality disorder has a prevalence between 0.2% and 3.3% and has several diagnostic criteria:

1. Disrespect and violation of rights of others
   A profound pattern of disrespect for and violation of the rights of others present from age 15 as evidenced by three or more of the following:
   1. Unable to conform to the social norm of abiding by the law as evidenced by repeatedly engaging in acts that may be grounds for arrest.
   2. Dishonesty as evidenced by repeated lying, using false names or swindling others for one’s own benefit or pleasure.
   3. Impulsiveness or inability to plan ahead.
   4. Irritability and aggressiveness as evidenced by repeated fights or acts of violence.
   5. Reckless indifference to the safety of the self or others.
   6. Constant irresponsibility as evidenced by repeated inability to keep regular jobs or meet financial obligations.
   7. Lack of remorse.

The diagnosis of antisocial personality disorder is formally not given before the age of 18. It is more in-depth and more related to lifestyle compared to conduct disorder. Psychopathy is distinguished from other personality disorders by its characteristic pattern of interpersonal, affective and behavioural symptoms:

1. Interpersonal symptoms
   Psychopaths are manipulative (1), self-centred (2), dominant (3) and cold-blooded (4).
2. Affective symptoms
   They show superficial and unstable emotions. They are unable to form long-term bonds with people. They have problems with principles and goals and demonstrate a lack of fear, empathy and guilty.
3. Behavioural symptoms
   Psychopaths are impulsive and sensation-seeking, tend to violate social norms and demonstrate criminal behaviour.

Cognitive distortions refer to inaccurate or biased ways of attending to or conferring meaning upon experiences. Self-serving cognitive distortions refer to cognitive distortions associated with externalizing behaviour. Self-centred (i.e. primary distortions) means according status to one’s own views, expectations, needs, rights, immediate feelings and desires to such a degree that the legitimate views of others are scarcely considered or disregarded altogether. Secondary distortions refer to pre- or post-transgression rationalizations that serve to neutralize conscience, potential empathy and guilty. It prevents damage to the self-image and includes blaming others, minimizing and mislabelling, and assuming the worst. Cognitive distortions are related to aggressive behaviour as it leads to moral decoupling.

Blaming others consists of misattributing blame to outside sources or misattributing blame for one’s victimization or other misfortune to innocent others’ (e.g. blaming the corona rules). Minimizing or mislabelling refers to depicting antisocial behaviour as causing no real harm or being acceptable or admirable. It can also include referring to others with a belittling or dehumanizing label (e.g. ‘that woman’). Assuming the worst refers to attributing hostile intentions to others (1), considering a worst-case scenario for a social situation as if it were inevitable or assuming that improvement is impossible in one’s own or others’ behaviour.

There are different risk factors for antisocial behaviour:

1. Historical risk factors
   1. Delinquency of the parents (e.g. antisocial genes).
   2. The number of delicts of biological parents.
   3. MAOS gen when being abused.
   4. Witness to violence in the family
   5. History of maltreatment as a child.
   6. Early disruption in family situation.
   7. Time spent in a children’s home.
   8. Poor school performance.
2. Individual risk factors
   
   1. Heartrate variability (i.e. higher heartrate variability is associated with higher empathy; better emotion regulation; better self-regulation).
   2. Inadequate care.
   3. Insecure attachment.
   4. High levels of stress.
   5. Little interest in school or work.
   6. Negative attitudes.
   7. Risky behaviour and impulsiveness.
   8. Substance use problems.
   1. Problems with handling anger.
   10. Lack of empathy or remorse.
   11. ADHD.
   50. Inadequate cooperation with interventions.
   1000.  
3. Social/contextual risk factors
   
   1. Low parenting skills of the parents.
   2. Lack of support from other adults.
   3. Dealing with delinquent peers.
   4. Peer rejection.
   5. Experienced stress and low coping skills.
   6. Disadvantaged neighbourhood.

Receiving inadequate care influences brain development and structure. The more stress, the higher the risk of aggression. A lower parental education could lead to more inadequate care, thus making a low educational level a risk factor. An insecure attachment leads to inadequate emotion regulation.

Inadequate care is associated with less coping (1), less decision making capacities (2), increased sensitivity to stress (3), increased vulnerability to peer influences (4), increased sensitivity to exclusion (5) and increased sensitivity to inclusion (6).

The longer a child has spent in a children’s home, the higher they scored on internalizing behaviour (1), physical complaints (2), anxious and depressive behaviour (3) and externalizing behaviour (4). Exclusion and suspension are strong predictors of delinquency and criminal behaviour. Truancy is an important predictor but the reason for truancy is very important.

The preference for risk and sensation seeking is highest during adolescence. Peer presence doubles the risk taking during adolescence and peer antisocial behaviour influences one’s own antisocial behaviour. However, self-reported resistance to peer pressure increases with age. Friendships, even bad ones, can be protective as the friendship quality is important. People with criminal friends had more property offenses (1), more violent reoffending (2) and fewer property offenses with structured leisure activities (3).

There are several protective factors for the development of antisocial behaviour:

1. Prosocial involvement.
2. Support from another person.
3. Close relationship with a prosocial adult.
4. Clear positive attitude toward intervention and authority.
5. Clear positive orientation to school or work.
6. Resilient personality.

Knowledge of protective factors leads to a more balanced risk assessment. This leads to a more well-rounded view of the patient and a more positive approach to risk prevention. This can be useful for the development of treatment goals. However, these protective factors are hardly present and hardly flexible in antisocial youth. Knowing more about juveniles with antisocial behaviour requires more than risk assessment.

Antisocial behaviour depends on the interaction between biological factors and stable versus instable families including the environmental x gene interaction. Risk and protective factors interact over time and conditions. Children with a disorder can be difficult to handle and this may provoke harsh parental strategies which will evoke more problematic behaviour which increases the risk of inconsistent care and antisocial behaviour.

Antisocial behaviour increases the risk for MBID (1), ASD (2), learning difficulties (3), language problems (4), child abuse (5), attachment disturbances (6) and acculturation problems (7).