This might sound like an unusual question for parents to ask, but thousands across the country ponder as much about their child every year. Struggling youth for a variety of reasons can and do infringe upon the rights and feelings of others at times. Stealing from family members, compulsive lying, bouts of violence, self centeredness, and a seeming indifference to looming consequences are just a few of the heartbreaking behaviors parents have to witness firsthand.
It is well known that addiction and mental health problems go hand in hand for youth. While depression, PTSD, anxiety, ADHD, and eating disorders get the bulk of the attention, it might surprise you to find out that Conduct Disorder is by far and away the most common mental health diagnosis in young addicts. It’s not even close. And Conduct Disorder is that very ominous risk factor for developing antisocial personality in adulthood, alternately referred to as sociopathy in the mainstream (I will use antisocial behaviors and sociopathy interchangeably, but some refer to sociopathy as only the very extreme of antisocial tendencies).
In this era of mental health care, where the unnecessary normalizing and pathologizing of behaviors have shamelessly become the standard at the expense of personal accountability, emerging sociopathy in young persons makes for highly inconvenient discourse. Some clinicians minimize the significance of such traits and focus mostly on how these struggling youth got to be that way, i.e. trauma. Others only recognize sociopathic behaviors as belonging to a populace hundreds of standard deviations from the norm and subsequently write off these youth as beyond hope when they encounter them.
However unpalatable the discussion may be, not addressing such important personality traits directly is akin to neglecting poor diet and exercise in a patient with heart disease. Would we avoid a talk on morbid obesity for those struggling with metabolic syndrome to spare the awkwardness? The relationship between sociopathy and addiction is well established and research is equally clear in demonstrating the influence of young antisocial behaviors on various clinical risks, prognoses, and trajectories. Youth with conduct disorder are more likely to have ADHD and future substance abuse and depression and a slew of other negative outcomes.
While we avoid using terms like conduct disorder and antisocial traits in describing our children with the best of intentions, we should also understand that denying the impact of such behaviors on their course can be folly. Such reasoning comes from the same wishful thinking that assumes all children were whole and "pure" before using drugs, which then leads to the misguided notion that sobriety from drugs alone will restore them to their prior state of innocence. In my clinical duties, I too often field “elephant in the room” questions from fearful parents who rightfully (and secretly) suspected early antisocial behaviors in their child, long before the grips of addiction or other psychiatric complications took hold. They noticed a lack of empathy for siblings, a propensity to be undaunted by consequences, an uncanny ability to manipulate while calmly masking any feelings of remorse or apprehension, and the like.
So what are parents supposed to do when they suspect sociopathic behavior in their child? And what does it mean for them? If my child stole from our family in the midst of substance abuse, will that behavior last when they are sober? Are they now changed forever or is it just a phase? At what point are interventions needed and how aggressive should they be? Is this the fault of my parenting? This is a controversial topic, so I think it best to frame our discussion further before moving on.
1. Withhold moral judgment: The diagnostic criteria for antisocial personality have not traditionally emphasized “why” an individual engages in sociopathic behaviors. For example, a young person can steal because of thrill seeking, impulsivity, anger, peer association, drug use, a misinterpretation of social norms or all of the above. There are many roads to the same destination. We know their end behaviors but not always their intentions, hearts, and minds. This is vital because it helps to withhold the moral judgment associated with these behaviors, which is critical for any parent to objectively help their child. “Good” and “bad” labels only make matters worse here. Kids who are addicted routinely engage in antisocial behaviors but only some are antisocial at baseline. The DSM V makes provisions for the exclusion of ongoing addiction - but that is a blog for another time.
2. Sociopathy is dynamic: I have had the pleasure of watching numerous young persons with a history of rather questionable behaviors do well later in life. These include kids who assaulted their parents, bullied others mercilessly, and spent time in prison. They can graduate from college, learn to maintain meaningful relationships, establish a sense of spirituality, and become caretakers for others. Young people who exhibit antisocial behaviors are largely dynamic. While everyone should be held accountable for their behaviors, we must again avoid the temptation of static judgments. We can be realistic and hold onto hope all at once.
3. Sociopathy is not all or none: Most young people who display antisocial qualities can at times be considerate, thoughtful, and judicious. Rather than a global absence of concern for the rights and feelings of others, I would say an overwhelming majority of youth with antisocial features are just more inconsistent in exercising this concern and forethought over time than their peers. In fact, a number of families are blind to emerging antisocial concerns because their child demonstrates a mix of strengths and weaknesses like every other child. "Well, there was that time when TIm really defended that other kid who was being bullied." It is only through an in-depth study of their patterns of behavior and an understanding of their psychology that the antisocial personalities emerge.
4. Sociopathy exists on a spectrum: Sociopathy is a pool with a deep and shallow end. Remorseless criminals might be on one extreme and teens who lie compulsively on another. Again, a great portion of young people with addiction for example have engaged in antisocial behaviors like lying and stealing but do not meet criteria for antisocial personality outright. This means that more children demonstrate antisocial traits than is commonly believed. It also means your child is not likely on the extreme statistically. So take a deep breath.
5. Elements of sociopathy can be genetic: Yikes! Wait, what are you saying about us? When we move on to talking about the neuro-behavioral mechanisms of sociopathy, this will make much more sense. I am not suggesting that the identification of antisocial behaviors in one family means everyone else in the family tree is de facto antisocial. Traits vary in magnitude between generations and at other times can pop up out of nowhere. For example, a family can have multiple members with not so meaningful sub-syndromal anxiety and a couple of members with intense, paralyzing obsessions or worries.
Parents should not be afraid of grappling with antisocial behaviors in their children. In the end, we might do more harm dancing around their emerging personality by pretending all of their problems stem linearly from depression or trauma or ADHD alone. The road to hope for our children's futures may require an honest appraisal of their journey.
Joseph Lee M.D. is a triple boarded physician and the medical director for Hazelden's youth services. He is the author of "Recovering My Kid: Parenting Young Adults in Treatment and Beyond." Find updates from Dr. Lee by signing onto twitter or facebook.
All content copyright Joseph Lee M.D.
Photo courtesy of Hazelden