Evidence of Treatment Progress and Therapeutic Outcomes Among Adolescents With Psychopathic Features

• Author: Michael F. Caldwell,Deborah Umstead,Gregory J. Van Rybroek,David J. McCormick
• Date: 01 May 2007
• Published date: 01 May 2007
• DOI: 10.1177/0093854806297511
• Subject Matter: Articles

EVIDENCE OF TREATMENT PROGRESS
AND THERAPEUTIC OUTCOMES
AMONG ADOLESCENTS WITH
PSYCHOPATHIC FEATURES
MICHAEL F. CALDWELL
DAVID J. MCCORMICK
DEBORAH UMSTEAD
Mendota Juvenile Treatment Center
GREGORY J. VAN RYBROEK
Mendota Mental Health Institute
This study examined the relation between psychopathic features and treatment progress in a group of 86 delinquent boys.
On admission to a specialized intensive treatment program, Psychopathic Checklist: Youth Version (PCL:YV) scores were
computed and subsequently compared with treatment progress. Treatment progress was measured using a series of daily
behavior rating scales and with a measure of institutional misconducts that required security intervention. The results found
significant improvement in behavioral and security measures with treatment. PCL:YV scores did not interact with treatment
progress. Regression analysis showed that initial, but not final, behavioral and security levels were predicted by PCL:YVscores.
The final scores were predicted only by the duration of treatment. Furthermore, violent recidivism during a 4-year follow-up
was predicted by final behavioral scores but not initial PCL:YV scores.
Keywords:
psychopathy; adolescent; treatment; violence; PCL:YV; recidivism
In recent years, interest in individuals with psychopathic personality traits has focused on
assessment methods, characteristics, and violence potential. Psychopathy has been defined as
a persistent disorder of personality characterized by a constellation of interpersonal, affective,
and behavioral features. Prototypical psychopaths are callous, egocentric, and deceitful, typi-
cally lacking in deep emotions, guilt, or remorse. They act impulsively and irresponsibly, gener-
ally developing a lifestyle of persistent violations of social norms and expectations (Cleckley,
1988; Hare, 1980, 1996), and their behavioral problems typically begin in childhood and con-
tinue through adulthood.
The perception that psychopathy does not emerge fully formed at the age of majority and
evidence that more general personality patterns can be accurately assessed in early childhood
(Lynam, 1998, 2002) have recently led to efforts to develop measures of psychopathic per-
sonality traits in children and adolescents (Forth, Kosson, & Hare, 2003; Frick, 1998; Lynam,
1998). Although there have been serious concerns about the appropriateness of labeling
a child or adolescent as a psychopath (Edens, Skeem, Cruise, & Cauffman, 2001), in recent
years evidence has emerged that psychopathic features can be reliably assessed in adolescents
(Edens et al., 2001; Forth et al., 2003).
AUTHORS’ NOTE: Correspondence about this article should be sent to Michael F. Caldwell, Mendota
Juvenile Treatment Center, University of Wisconsin–Madison, 301 Troy Dr., Madison, WI 53704; e-mail mfcald-
well@wisc.edu.
CRIMINAL JUSTICE AND BEHAVIOR, Vol. 34 No. 5, May 2007 573-587
DOI: 10.1177/0093854806297511
© 2007 American Association for Correctional and Forensic Psychology
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CRIMINAL JUSTICE AND BEHAVIOR
The view that psychopaths are untreatable, or may even be made worse with treatment,
has been bolstered by several studies that documented poor treatment response and out-
comes for adults with psychopathic features. In an early study, Rice and her colleagues
(Rice, Harris, & Cormier, 1992) found that psychopathic adult men who had participated in
a treatment program compared with similar men who had not participated in treatment were
as likely to recidivate generally (90% vs. 87%, respectively) and more likely to recidivate
violently (55% vs. 77%, respectively). More recently, several studies have documented that
higher scores on measures of psychopathic traits predict poorer adjustment and progress in
treatment settings (Hare, Clark, Grann, & Thornton, 2000; Hobson, Shine, & Roberts, 2000;
Looman, Abracen, Serin, & Marquis, 2005; Ogloff, Wong, & Greenwood, 1990; Richards,
Casey, & Lucente, 2003). Similarly, numerous studies have documented that psychopathic
features predict general and violent recidivism. (See Hare et al., 2000, for a detailed review.)
Although there have been recent efforts to provide treatment models that may be effective
with treating psychopaths (Doren, 1997;Wong, 2000; Wong & Hare, 2005), clear-cut demon-
strations of effective treatment programs have not yet emerged. Some have questioned
whether even attempting to treat psychopaths may be approaching an unethical practice on
the grounds that it may make them more prone to future violence (Salter, 2005). However,
several authors have suggested that the clinical pessimism surrounding the treatability of
individuals with psychopathic features may not be well supported (D’Silva, Duggan, &
McCarthy, 2004; Salekin, 2002; Skeem, Monahan, & Mulvey, 2002; Vincent, 2006).
Studies of the treatment response and institutional behavior of adolescents with pro-
nounced psychopathic features have revealed several consistent findings. Juveniles with
more psychopathic features tend to be more disruptive and aggressive in institutions and
treatment programs, are more apt to drop out, and make less progress in treatment. There is,
however, some indication that juvenile offenders with more psychopathic features may
respond to extended, intensive treatment (Caldwell, Skeem, Salekin, & Van Rybroek, 2006).
ADOLESCENTS WITH PSYCHOPATHIC FEATURES AND
INSTITUTIONAL AGGRESSION
In an early examination of the issue, Forth, Hart, and Hare (1990) found that scores on
a modified version of the Psychopathy Checklist–Revised (PCL-R; Hare, 1991) were sig-
nificantly correlated with the number of institutional charges for violent behavior in a group
of 75 young male offenders. Similarly, Brandt, Kennedy, Patrick, and Curtain (1997) used a
modified version of the PCL-R to assess psychopathic features in a population of 130 insti-
tutionalized male offenders (ages 13–19). They found that psychopathy scores were signifi-
cantly correlated with verbal and physical rule infractions and with intensive supervision
placements for more serious misconduct.
In a prospective study of 72 adolescent male psychiatric patients, Stafford and Cornell
(2003) examined the relation between institutional aggression and psychopathic features.
After controlling for age, sex, length of institutional stay, and socioeconomic status, they
found that scores on a modified version of the PCL-R (Hare, 1991) predicted staff ratings
of overall institutional aggression, verbal and covert aggression, and aggression directed
toward peers. Similarly, Kaplan and Cornell (2004) evaluated the relation between insti-
tutional aggression, psychopathic features, and attention deficit hyperactivity disorder
(ADHD) in a population of 122 adolescent male offenders. Using a stepwise regression

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575
procedure they found that, after controlling for age, ADHD symptoms and diagnosis, and
history of psychostimulant medication use, scores on the Psychopathic Checklist: Youth
Version (PCL:YV; Forth et al., 2003) significantly predicted institutional assault and a history
of violent crime.
In a study of residential adolescent male offenders, Murdock-Hicks, Rogers, and Cashel
(2000) found that those who scored high on the Psychopathy Checklist: Screening Version
(Hart, Cox, & Hare, 1995) manifested a significantly higher rate of violent institutional
infractions compared with lower scorers.
ADOLESCENTS WITH PSYCHOPATHIC FEATURES
AND TREATMENT PROGRESS
Similar to the adult literature (Harris & Rice, 2006), studies examining the relation between
psychopathic features in juveniles and progress in treatment have not been encouraging.
Rogers, Vitacco, Cruise, Sewell, and Neumann (2002) examined the relation between psycho-
pathic features and treatment outcomes in 82 adolescent offenders with substance abuse and
externalizing behavior disorders who were treated in a state hospital setting. Psychopathic fea-
tures were assessed with the Psychopathy-Screen scale of the Survey of Attitudes and Life
Experiences (Rogers et al., 2002). They found that psychopathic features predicted the number
of behavioral problems described in the discharge summary and were inversely related to staff
ratings of the level of improvement at the time of discharge.
O’Neill, Lidz, and Heilbrun (2003) examined the relation between treatment process and
outcomes and psychopathic features in 64 male adolescents who were treated for substance
abuse problems in a partial hospitalization program. They reported a significant negative
correlation between scores on the PCL:YV and the quality of program participation and
program attendance, the number of consecutive clean urine tests and the percentage of clean
urine tests, staff ratings of clinical improvement, and criminal recidivism in the year after
program completion.
In a study comparing the PCL:YV and two self-report measures of psychopathic features,
the Antisocial Processes Screening Device (Frick & Hare, 2001) and a modified version of
the Child Psychopathy Scale (Lynam, 1997), Spain, Douglas, Poythress, and Epstein (2004)
followed 85 adolescent male offenders in residential treatment. They found that each mea-
sure was significantly correlated with the rate of physical and verbal aggression recorded in
the participant’s record. The self-report measures, but not the PCL:YV, were significantly
correlated to the number of days it took youths to progress to the second treatment program
privilege level.
In a similar study, Falkenbach,...