The Fear Factor Read online

  So what was going on with Dylan? The first step in finding out was to interview him.

  The day of the interview I didn’t know what to expect. It was my first clinical interview of any kind, much less one with a child with rage and violence issues like this one. Images from The Silence of the Lambs and One Flew over the Cuckoo’s Nest flashed through my mind as I made my way through the daffodils outside Building 15K alongside my fellow postdoc and research partner, Liz Finger. Liz is a brilliant Harvard-trained neurologist who is insightful and perceptive, but she had as little prior experience with children like Dylan as I did. Together we walked toward the NIH Clinical Center, where Dylan was being housed in a locked ward, with mixed feelings of excitement and trepidation. Would Dylan be hostile? Would we be safe? Was he going to be restrained somehow? We were both smallish women, and prior to beginning the project we had received a rundown of basic safety procedures with potentially violent research subjects. Never allow any loose pens, pencils, or other potential weapons near the subject. Stay at least three feet away, out of arm’s reach. Never let the patient get between yourself and the door. Don’t turn your back. We hoped these feeble measures wouldn’t be our only source of protection.

  We made our way through the Clinical Center’s gleaming metal-and-glass atrium, weaving through the physicians and patients streaming through it, the physicians’ brisk and purposeful gaits in stark contrast to the patients, who clung unsteadily to their IV racks or slumped in chrome-plated NIH-issue wheelchairs. We hung a right and came to the pediatric inpatient ward, where, after a moment’s wait, we were buzzed in. “Here to see Dylan?” said the friendly, round-cheeked nurse who greeted us at the door. “Follow me.”

  Toward the end of the hallway she pointed at a nondescript, blond wood door, one in a long succession of identical doors, and said, smiling, “Here you go!” before departing. We hesitated a moment, then turned the handle and walked in.

  The room was small and spare, but cheerful and tastefully decorated in the desert tones of a modern hospital. Dylan perched on the corner of a neatly made twin bed in a posture that suggested he had been waiting for us. I hoped I didn’t look as taken aback as I felt when I saw him. I briefly thought the nurse had gotten the room wrong. This was the Dylan whose files we’d been poring over? This was the boy whose parents and sisters lived in fear of him? The knife-wielding menace? The shit-smearer? This boy looked like he’d wandered in off the set of a cereal commercial. He was gangly-legged and suntanned, with a shock of white-blond hair and a nose spattered with freckles. He stood up politely to shake our hands, evidently well practiced in the art of greeting strange adults. When he smiled, it was such a broad, open smile, so incongruous with everything we had heard and read about him, that I couldn’t help myself. I liked him at once.

  I never stopped liking him. We had a perfectly lovely conversation that day, as we did every time we met afterward. Dylan told us about his home in Arizona, about his love of playing golf with his mother, whom we met that day as well. She was also a dazzling mosaic of tan skin and gleaming teeth and expensive golf clothes, and her affection for Dylan was clear. In the snug confines of that hospital room, with its soft colors and shining maple laminate floor, keeping myself between Dylan and the door was the last thing on my mind. My abiding impression was one of friendliness and warmth.

  Liz and I spoke to Dylan in private for a while, and he confirmed that he had indeed done all the things we had heard about. But the way he explained everything to us, all the wild behaviors somehow lost their sharp edges. Every explosion was just the inevitable outcome of a bad day—he was tired, he was frustrated, his sisters had been bothering him. He never really meant to hurt anybody. He didn’t know why he threatened people, or why they believed he was serious when he did. He just got upset. All his explanations seemed so reassuringly normal. If anything seemed out of the ordinary, it was that Dylan seemed a little more fidgety than the average adolescent boy, changing positions often, animated by a restless energy that comported with the nurses’ observations of his impulsiveness and difficulty concentrating, but that was the extent of it.

  We left the interview shaking our heads. Whatever we had been expecting to find that day, we hadn’t found it. He seemed like such a nice kid. And the nurses we spoke to after we interviewed Dylan and his mother (separately) said that he was often sweet to the younger children on the ward—reading to them or helping them with their schoolwork.

  Dylan had just demonstrated to us why using an interview alone to evaluate psychopathy is a bad idea.

  The modern clinical definition of psychopathy is largely based on the work of the twentieth-century psychiatrist Hervey Cleckley, which he detailed in his masterful book The Mask of Sanity. The text is a wide-ranging exploration of the meaning of sanity and insanity, morality and immorality, and includes fifteen sharply observed case studies that illustrate how psychopathy is distinct from other psychiatric disorders. After presenting his case studies, Cleckley summarizes the essential characteristics of psychopathy. He begins with an observation that echoes Tony Savage’s description of Gary Ridgway, the Green River Killer:

  More often than not, the typical psychopath will seem particularly agreeable and make a distinctly positive impression when he is first encountered. Alert and friendly in his attitude, he is easy to talk with and seems to have a good many genuine interests. There is nothing at all odd or queer about him, and in every respect he tends to embody the concept of a well-adjusted, happy person. Nor does he, on the other hand, seem to be artificially exerting himself like one who is covering up or who wants to sell you a bill of goods. He would seldom be confused with the professional backslapper or someone who is trying to ingratiate himself for a concealed purpose. Signs of affectation or excessive affability are not characteristic. He looks like the real thing.

  Cleckley could not have described Dylan better if he had been sitting in on the interview with Liz and me. Not simply less maladjusted than the average child in a locked psychiatric inpatient ward, Dylan genuinely came across as a friendly, normal, well-adjusted twelve-year-old. This stark contrast between his frequent threats and violence and his outwardly friendly and normal appearance was the second clue that Dylan’s problem was not simply poorly regulated moods. Together, these two pieces of information—unusually violent behavior even for a psychiatric patient, as evidenced by his files, and a hypernormal, even charming, outward appearance that betrayed no hint of how violent he could be—suggested that Dylan might be psychopathic.

  The concept of a psychopathic child makes many people queasy. In some ways, the two categories seem mutually incompatible. Children, even badly behaved ones, are viewed as maintaining some fundamental innocence compared to adults, whereas psychopaths are viewed as fundamentally depraved. But of course, neither stereotype is totally true. Children, just like adults, are capable of cruelty and violence, and even highly psychopathic people are not cruel or violent all of the time. Perhaps our resistance to the idea of a person being both a child and psychopathic—of there being overlap between these two groups—reflects our moral typecasting biases, according to which children fill the role of moral patients and psychopaths fill the role of moral agents.

  But in reality, psychopathy is a developmental disorder. It does not emerge out of nowhere in adulthood. Essentially, without exception, all psychopathic adults first showed signs of psychopathy during adolescence or childhood. This means that for every psychopathic adult out there in the world, there was once a psychopathic child.

  The title of a widely circulated New York Times Magazine article from 2012 posed a highly provocative question: “Can you call a 9-year-old a psychopath?” The question is not so provocative from a scientific perspective. The definition of an adult psychopath is anyone who meets a specific cutoff on a measure called the Psychopathy Checklist—Revised (PCL-R), a 40-point scale scored using information from an interview and background files. In the United States, an adult who scores at least 30 poin
ts out of 40 is deemed a psychopath. This is a debatable practice, as there is no functional difference between people who score 31 versus those who score 29 (not to mention that any two assessments of the same person can and usually do differ by at least two points), but it remains the current standard. There is a nearly identical 40-point scale designed for use in children as young as ten called the Psychopathy Checklist: Youth Version (PCL:YV). It is possible for a nine-year-old to possess all the personality and behavioral traits that would lead us to label an adult a psychopath, and such nine-year-olds often do go on to become adult psychopaths.

  But from a broader cultural and moral perspective, the answer to the question “can you call a nine-year-old a psychopath?” is: absolutely not. The terrible stigma that results from labeling a child a psychopath cannot be ignored. And although every adult psychopath began as a psychopathic child, the reverse is not true: many children with high psychopathy scores do not go on to become adult psychopaths. Why is not entirely clear. We know very little about how the brain develops during adolescence, and some children may genuinely remit as their brains rewire themselves in the period leading up to adulthood. Remission could occur in response to favorable changes in a child’s environment, or perhaps as a result of innate developmental processes. Other children who appear to remit were probably misclassified to begin with, such that what looked like emerging psychopathy was instead an unusual expression of early bipolar disorder, schizophrenia, or even autism. For these reasons, no responsible researcher or clinician will ever label a child a “psychopath.” Making this rule easy to follow is the fact that there is no official cutoff score on the PCL:YV, which removes the temptation to pin a label on a child who might well turn out to be something quite different. You will never hear me call any of the children we worked with a psychopath. They simply were not.

  But the fact that children can strongly express psychopathic traits cannot and should not be ignored. So researchers and clinicians try to split the difference by referring to such children as possessing psychopathic traits or tendencies—or, for concision, as just “psychopathic” (“psychopath-ish” not being a real word). Often the phrase callous-unemotional traits is also used as an even less incendiary description of the key personality traits that typify psychopathy. DSM-5 eschews mention of psychopathy entirely, but there is a new designation reserved for children who possess the antisocial and callous features of psychopathy, which is the inelegant but accurate designation conduct disorder with limited prosocial emotions. This designation is satisfied if a child has conduct disorder and also exhibits at least two of four key characteristics across different settings: lack of remorse or guilt, callousness (a lack of empathic concern), lack of concern about performance in important activities like school or work, and shallow or deficient affect. This specifier did not yet exist when we were beginning our research. So, for our purposes, any child with a diagnosis of either conduct disorder or its developmental precursor, oppositional defiant disorder, and a PCL:YV score of at least 20 was deemed to possess sufficient psychopathic traits to qualify for our study.

  Was Dylan such a child? Liz and I each evaluated him separately using the PCL:YV, which we had been trained to administer by David Kosson and Adelle Forth, two of the psychopathy experts who created the scale. We took into account both his behavior during the interview and all of the background information we had collected about him. Dylan scored a 0 on a few items on the scale, including “serious violations of probation,” since he had never been on probation, and “grandiose sense of self-worth,” since he seemed merely confident, not narcissistic or grandiose. But as we went through the scale, his score continued to mount. “Early behavior problems?” Yes. “Poor anger control?” Definitely yes. “Impression management?” Also yes—among other things, during his interview he consistently angled to portray himself in the best possible light, despite our already knowing the facts of his background. “Failure to accept responsibility?” Interesting—also yes. Despite the favorable impression we had gotten of Dylan overall, when we reviewed our interview notes it was clear from both Dylan’s and his mother’s accounts that Dylan never accepted any responsibility for his behavior. Everything was always the fault of some external factor—a bad day, someone else bothering him. The same was true for “lacks remorse.” He’d had ample opportunities to express remorse for the effects of his actions on others, but he never really did. Instead, he minimized the seriousness of his actions and blamed them on others rather than acknowledging how much distress he had caused his family and teachers.

  Liz tallied up our scores when we were done, reaching almost perfect agreement in our assessment of Dylan. He scored a 24. We had our first research subject.

  That marked the beginning of a long, often grueling process of recruiting several dozen children with psychopathic traits for our brain imaging studies. A few, like Dylan, were sent our way by other investigators at the NIH, but most we had to find ourselves. If you assume that at least one child in 100 would score at least 20 on the PCL:YV (which is, if anything, a lowball estimate), a metropolitan area the size of Washington, DC, contains thousands of potentially eligible children. But recruiting them is a difficult business. There are no advocacy organizations or listservs for parents of children with psychopathic traits like there are for parents of children with autism or ADHD. So we had to create advertisements. But they had to be delicately worded. “Is your child psychopathic?” was not going to fly. Not only would it be inflammatory, but many parents of eligible children don’t think of their children in these terms (although some do). So we instead asked parents about their children’s behavior. Our advertisements, which we posted in print media and as posters near family courts and probation facilities, asked, “Does your child have behavior problems and not feel guilty when he/she does something wrong?” These ads yielded very few calls relative to the number of potentially eligible kids out there, perhaps because most parents with a child who met these criteria were already stretched thin—perhaps too thin to participate in anything that didn’t hold out the promise of treatment. But eventually, calls from parents began to trickle in.

  If you have ever felt compassion for anyone in your life, feel compassion for the parents of these children. During their initial phone screenings, and later during interviews in the lab, the stories these parents told us about their children were heart-rending. By the time they called us, their children’s misbehavior had usually been going on for many years. There was rarely a single calm day in their homes. Like Dylan’s parents, they worried every day about what new episode of violence or theft or destructiveness the day would bring, about the safety of their other children, and about their own safety as well.

  Several of them had been seriously injured by their children. One mother told us about her son shoving her so hard during a fight that she broke her wrist when she fell. A father told us that his preteen daughter had kicked him in the face with such force that he feared he might lose his vision in one eye. What had the father done to earn such a kick? He had no idea. He’d been sitting on the floor watching television at the time. We heard from parents whose children stole from them constantly—collectively hundreds or thousands of dollars. No matter where cash and valuables and credit cards were hidden, it never seemed to stop the thievery. That wasn’t even counting all the costs the parents incurred from damage to their possessions—wrecked cars, dead pets, fires. The parents were lied to. Manipulated. Subject to endless haranguing by school teachers and administrators fed up with the children’s misbehavior in school—a problem that the parents were even more powerless to fix than the misbehavior at home. Most of the children had been thrown out of at least one school, sometimes several, often for injuring classmates or teachers. One mother told us that her daughter brought a glass bottle of juice to school specifically so that, when she finished the drink, she could smash the empty bottle across the face of a teacher she disliked, which she did, right in the front of the classroom, leaving a g
ash that required seven stitches to repair. The mother of another child had had to retrieve her son from school so often when he was suspended—at least a dozen times—that she ended up being fired from her job for lost work. She was a single mother, and the strain of it all was so severe that she was briefly institutionalized.

  I remember that interview mainly owing to her son Michael’s response when I probed a bit to ask how he felt about all the trouble he had caused his mother. Did he feel badly that he had caused her so much suffering? I was curious in part because, much like Dylan, Michael seemed to have a very sweet relationship with his mother when they visited us. The question stumped him, though. I think he realized he should feel some sense of remorse or guilt, but somehow he couldn’t conjure up the feeling I was asking about. Finally, he said, “Well, the things I do hurt her, right? But she doesn’t say how much, so it doesn’t really have an effect on me.” Michael and Dylan had little in common other than both being adolescent boys. But one clear commonality was that no matter how much hurt and distress they caused other people, it didn’t seem to occur to them to feel badly about it.