尽管对其确切轮廓分歧,但大多数精神病性人格障碍的概念都强调了情绪超脱的特征,包括冷酷无情,未能形成紧密的情感纽带,低焦虑的倾向,无情的无情和欺骗性。然而,大多数精神病措施都超出了这些人际交往和情感特征,以评估反社会行为的重复参与,这是许多学者认为这是该结构的外围。主要是,这是因为大多数措施基于精神病清单重新定义的(PCL-R),该措施像情绪超脱的特征一样,权衡过去的暴力和反社会行为。在过去的十年中,研究人员将这种成人的精神病措施向下扩展到青少年和儿童,目的是评估“少年精神病”。尽管关于在年轻人的性格达到相对发展稳定之前,就诊断精神病的适当性进行了持续的争议,但这项研究已经取得了巨大的动力。大多数当代研究和几乎所有实际兴趣都围绕着预测年轻罪犯的暴力和反社会行为的少年精神病的可靠性和实用性。在此条目中,注意到这一运动,但是强调了将这种结构扩展到年轻人的有效性的研究。理论上驱动的研究对基于精神病的潜在机制的研究揭示了情绪超脱的重要性,这可能是年轻人中精神病的一种表现。但是,没有令人信服的证据表明,在过渡到成年期间,所谓的精神病特征(a)保持稳定,或者(b)对治疗没有反应。这限制了精神病措施的效用,以告知与青年有关的长期后果的法律决定。 Although relevant measures have been developed for children as young as 3 years, the focus of this entry is on preteens and adolescents.
Extending Psychopathy from Adults to Youths
Several factors have encouraged the extension of psychopathy from adults to youth. Foremost among them are (a) the recognition that the chief tools for diagnosing psychopathy predict violence and criminal recidivism and (b) the juvenile justice system’s increasingly punitive policies, which have created a demand for identifying inalterably dangerous youths. Although researchers hoped that psychopathy assessments would be used to identify a subgroup of at-risk youths to target for intervention, recent legal reviews suggest that the youths identified are likely to be excluded from treatment and set up for harsh sanctions.
Most measures of juvenile psychopathy modify the PCL-R items and scoring criteria to reference youths’ peer, family, and school experiences. They are built on the assumption that the features of psychopathy manifested by adult psychopaths will, when exhibited in youths, identify a small subgroup of offenders who are maturing into psychopaths. That is, psychopathy is manifested similarly, whether one is 13 or 33 years old. This assumption is challenged by a study of clinical psychologists’ conceptions of juvenile psychopathy. Clinicians viewed some of the features of adult PCL-R psychopathy (e.g., impulsivity, the failure to accept responsibility, a parasitic lifestyle, criminal versatility) as nonprototypic of juvenile psychopathy. Although this raises the possibility that the manifestations of psychopathy differ as a function of developmental stage, no “bottom-up” measures of juvenile psychopathy have been developed.
Reliability and Predictive Utility of Juvenile Psychopathy Measures
The most widely validated measures of juvenile psychopathy were derived from the PCL-R, including the Psychopathy Checklist: Youth Version (PCL:YV), the Antisocial Process Screening Device (APSD), and the Child Psychopathy Scale (CPS). Like its parent measure, the PCL:YV is based on a clinical interview and file review; the other measures are based on self- or collateral report. Perhaps, given these method differences, the PCL:YV correlates only moderately with the remaining measures.
These measures share two general strengths. First, each has been shown to be reliable (interrater, internal consistency, and/or short-term test-retest). Second, each has demonstrated some utility in predicting youths’ violent or antisocial behavior. The typical degree of association with these behavioral outcomes is similar to that observed in adults (i.e., r ^ .25). Although most prospective studies follow youths for only 1 to 2 years, one retrospective study indicates that youths’ (mean age = 16) file-based PCL:YV scores moderately predict violent recidivism over an average 10-year follow-up period. Most of the PCL:YV’s predictive utility in this study, however, was attributable to its assessment of an impulsive, antisocial lifestyle rather than traits of emotional detachment. This finding is consistent with much of the adult literature and challenges the assumption that the measure’s association with violence is an indication that emotionally detached psychopaths use violence to prey on others. Instead, the measures may tap traits of aggression or externalizing features that predict violence but are not specific to psychopathy.
少年精神病的构建有效性:潜在的机制和病因
For such reasons, predictive utility (which seeks clinical utility) cannot be mistaken for construct validity (which seeks construct identification). To determine whether psychopathy is a valid construct when applied to youths, juvenile psychopathy must be (a) evaluated against a validation hierarchy dictated by a theory of the disorder and (b) shown to be a stable personality disorder that does not dissipate as youths become adults.
Despite the differences among them, most theories describe psychopathy as a largely inherited affective or cognitive processing deficit. These theories dictate a validation hierarchy that places pathophysiologic and etiologic mechanisms at the top, as they offer the greatest potential for explaining the disorder and potentially altering its course. The question is whether diagnostic criteria for juvenile psychopathy identify a homogeneous group of youths with clearly delineated deficits and largely genetic pathophysiology.
Paul Frick and his students have begun to address this question. Their work highlights the importance of features of emotional detachment, or “callous/ unemotional” (C/U) traits, in defining juvenile psychopathy. Theoretically, traits of emotional detachment are underpinned by a fearless temperament and deficient processing of emotionally distressing stimuli, which causes insensitivity to socializing agents and interferes with the typical development of conscience. At the symptomatic level, Frick and his colleagues have found that youths with traits of emotional detachment tend to be fearless, thrill and adventure seeking, and low in anxiety. At the pathophysiological level, they have found that emotionally detached traits identify— among a pool of youths with early and persistent antisocial behavior—those who possess information-processing and emotional deficits similar to those found among psychopathic adults. These include reduced sensitivity to cues of punishment when a reward-oriented response set is primed and diminished reactivity to threatening and emotionally distressing stimuli. Although such results might be interpreted as evidence that psychopathy is genetically influenced, caution should be exercised in drawing premature inferences because the heritability of these laboratory variables is unclear.
Only one behavioral-genetic study of psychopathy has been conducted with youths to date. In this study, psychopathy was operationalized using teachers’ ratings of C/U traits on an unvalidated but internally consistent scale. Based on a selection of 661 7-year-old probands with extreme C/U traits (>1.3 SD), the authors found concordance rates of 39% and 73% for dizygotic and monozygotic twins, respectively, yielding an estimate of moderate heritability for C/U traits (h = .67). Although observational studies suggest that childhood maltreatment relates more strongly to antisocial behavior than features of emotional detachment per se, more research is needed to determine whether features of emotional detachment are more highly heritable.
总而言之,现有的研究为定义少年精神病的情绪超脱或C/U特征的有效性提供了一些支持。这些特征的重要性得到了心理测量研究的支持。应用项目响应理论的研究表明,人际关系和情感项目传达了有关潜在少年精神病结构的更多信息,而不是利用侵略性和反社会行为的项目。最近开发了一些少年精神病的衡量标准(例如,青年精神病性状库存库存;冷酷无情特征的清单)专注于情绪超脱,认为反社会行为。将来的研究仍然是,确定这些措施是否比其前辈更“干净地”评估结构。
少年精神病的延展性
The fact that we can reliably assess features of emotional detachment in youths that relate in a theoretically coherent manner to cognitive and affective deficits provides some support for extending psychopathy measures downward from adults to youth. Presently, however, we lack the necessary collateral evidence that what we are assessing in youths is psychopathy, a personality disorder that will remain stable into adulthood.
Scholars have expressed two main concerns about the stability of juvenile psychopathy. First, downward translations of the PCL-R include normative and temporary features of adolescence such as impulsivity, stimulation seeking/proneness to boredom, poor behavior controls, and irresponsibility. At least one study indicates that measures of juvenile psychopathy correlate moderately with measures of psychosocial maturity. To the extent that measures of juvenile psychopathy tap construct-irrelevant variance related to psychosocial maturity, a youth’s score will gradually decrease as he or she matures. It is possible that recent measures of juvenile psychopathy that focus specifically on emotional detachment may capture less construct-irrelevant variance related to psychosocial maturity. Indeed, a cross-sectional item-response theory study indicates that PCL:YV items that assess emotional detachment are more defining of psychopathy across age groups than items that tap impulsive, antisocial behavior.
The second concern is that there is no compelling evidence that youths assessed as psychopathic will mature into psychopathic adults. Because personality and identity may not be well formed until adulthood, our nosological systems generally forbid applying diagnoses of personality disorders to children and adolescents. Although psychopathic adults probably manifested similar traits when they were younger, relatively few youths with psychopathic features may mature into psychopathic adults. Reasoning by analogy, the majority of children with conduct disorder desist acting out and do not mature into adults with antisocial personality disorder.
已经进行了三项相关研究。首先,APSD反复给予100个非参考四年级学生。在4年的时间里,APSD得分和等级顺序的稳定性非常好(阶级间相关性[ICC] = .80),这表明父母评分从童年晚期到青春期早期变化很小。其余的两项研究集中在从青春期到成年的过渡。在第二项研究中,在13岁时对CPS进行了200多名年轻人,并在24岁时筛选了PCL的筛查版本。在这10年内,稳定性相对较差(ICC = .27),并且大多数shared variance was between the CPS and PCL’s antisocial scale. Of the adolescents who obtained extremely high CPS scores (i.e., the top 5%) at age 13, less than one-third (29%) were classified as psychopathic at age 24. In the third study, PCL measures were repeatedly administered to approximately 200 adolescents and 100 adults. Over a 2-year period, the stability of adolescents’ PCL:YV scores was limited (ICC = .34). Adolescents’ PCL:YV scores decreased significantly more than adults’ PCL-R scores, indicating that psychopathy assessed during adolescence is less stable than that assessed during adulthood.
精神病的明显特征不仅可以随成熟度的函数而变化,而且还可以随着干预的函数而变化。最近的研究结果挑战了关于精神病的长期治疗悲观主义。尽管已经对青年进行了三项研究,但只有一项是前瞻性的,其中包括对照组。在这项研究中,大约有150名具有明显的PCL:YV得分和长期行动历史的年轻人,参加强化治疗计划的人在释放后一年剧烈败将的可能性要比那些像往常一样参加治疗的人少2.4倍。
青少年精神病的法律影响
尽管少年精神病是一种有前途的结构,但可用的证据不能支持其对具有长期后果的青年的法律决定的应用。首先,鉴于缺乏证据表明这些措施确定了将成熟成人精神病患者成熟的不可分化的危险年轻人,因此不适当采取这些措施来确定是否应在成人法院系统中尝试青年。其次,这些措施不应用作治疗计划的排除标准。实际上,具有高精神病分数的少年应被重新塑造为需要密集治疗的高风险病例,而不是无望的病例以丧失能力。
这些措施的哪些法律用途可能是合适的?鉴于他们的预测效用,人们可能会使用一定程度的少年精神病作为风险评估工具,以告知有关安置的短期决策(尤其是安全级别)。但是,为青年设计和验证的风险评估工具可用。在选择精神病的诊断度量上,而不是经过验证的风险评估工具之前,必须考虑使用不愉快的标签“精神病患者”污名化儿童或青少年的潜力。对少年司法专业人士和模拟陪审团的研究表明,该标签引起了人们认为年轻人不可分割的危险的假设。尽管这种假设不享有经验支持,但它使决策者摆脱了康复的努力,无法实现严厉的制裁和丧失能力。由于青春期是一个重大发展变化的时期,因此必须在将这种结构作为评估少年罪犯的组成部分之前,了解精神病的稳定性,性质和表现。
References:
- Edens,J。F.,Skeem,J。L.,Cruise,K。R.和Cauffman,E。(2001)。评估“少年精神病”及其与暴力的关联:批判性审查。行为科学与法律,19,53-80。
- Frick, P. J., & Dickens, C. (2006). Current perspectives on conduct disorder. Current Psychiatry Reports, 8, 59-72.
- Salekin,R。T.(2006)。儿童和青少年的精神病。在C. J. Patrick(编辑)中,《精神病特征手册》(第389-H4页)。纽约:吉尔福德出版社。
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