3
THE PSYCHOPATHIC BRAIN
ON THE THIRTIETH of March, 2004, Jeremy and I drove away from Somerville, Massachusetts, bound for Washington, DC, with my cat and a U-Haul full of rickety furniture. Two days later, on April 1, I arrived at the NIH to start my new job.
Upon arrival, my initial impression was—April Fool!—that a colossal prank had been played on me and I actually didn’t have a job there. Coming through the gates for the first time, I tried to locate my building on the campus map. The NIH campus holds, depending on how you count, a jumble of about eighty haphazardly numbered buildings—8 is across from 50, which abuts 12. After several minutes of scanning the map, I was forced to concede that my building number wasn’t on it. I asked the security guards for help, but none of them had ever heard of it. “Fifteen Kay? What is that? Is that an NIH building?”
In desperation, I started wandering through the vast, rolling campus, and miraculously I finally stumbled upon my destination—a sweet Tudor-style cottage not at all befitting the sterile designation “15K,” sitting tucked away on a daffodil-strewn hillside in a remote corner of the campus. It was so small that NIH maps rarely bothered labeling it. No one inside seemed to know who I was or why I had come. A secretary asked me for any paperwork that could confirm I had been hired, and I realized that no one had ever sent me any. I tried to locate James, but none of the office doors had names or numbers on them. When I finally found his office, it was dark and shuttered. “What the hell is going on? What kind of place is this?!” I wondered in a fury.
As I would come to learn, the NIMH is a byzantine kind of place, especially for newcomers. Paperwork confirming my postdoc was probably wending its way through a labyrinth of cubicles somewhere on campus, but it hadn’t yet gotten a final stamp of approval. No matter. I had a computer, I had a desk, I eventually located James, and I was ready to get to work.
My first goal was to publish my dissertation. In a series of five studies, I had found that sensitivity to fearful facial expressions is a reliable predictor of empathic concern in response to others’ distress. The first study found that participants who were best at recognizing fearful expressions offered more money and time to help Katie Banks, the distressed woman I had portrayed in the radio interview. The remaining studies found that volunteers who were best at recognizing fear also evaluated strangers’ physical appearances more kindly if they thought those strangers would receive the evaluations, and they expressed a greater desire to help distressed strangers described in short vignettes.
James Blair’s research could be the key to understanding these odd findings. In 1995, James had published a novel hypothesis of psychopathy. A hallmark of psychopaths is their frequent perpetration of proactive aggression—cold, purposeful aggression, be it physical, verbal, or social—aimed at achieving some goal. Criminals who kill people after robbing them so they can’t be identified later, or who use threats of violence to extort money, are often psychopaths. James proposed that the mechanism that prevents most of us from engaging in these sorts of behaviors—and that appears to be malfunctioning in psychopaths—is a system he termed the Violence Inhibition Mechanism, or VIM (later updated and renamed the Integrated Emotion Systems model).
James developed the idea of the VIM based in part on the work of animal behavior experts like Konrad Lorenz and Irenäus Eibl-Eibesfeldt, who observed that, among group-living animals in the wild, conflicts over resources or status can be quelled before actual aggression erupts through the use of body postures and vocalizations that send specific signals. Take wolves, which are good analogs to humans for two reasons. First, the organization of their packs is not unlike small bands of prehistoric humans or modern hunter-gatherers. Both consist of smallish, mutually dependent, and interrelated groups of adults and their young who work cooperatively to defend their territory, care for juveniles, and hunt for food. Second, many behaviors that wolves use to communicate are familiar to us because they have been retained in wolves’ domesticated descendants—our dogs.
If, during a walk in the woods, you were to encounter a wolf that approached you with its fur standing on end, its body stiff, and its tail and head held high, growling in a low tone, you would need no translator to tell you how much trouble you were in. The wolf would be telling you that loud and clear. Not because it saw you as prey, mind you—wolves don’t bother communicating like this with animals they are planning to eat. This wolf’s behavior is an intimidation display—one that is meant to be seen and that signals it views you as a competitor or a threat, perhaps because you wandered too near a kill or its pups. So what would you do?
If you were you (a human), you’d be in a bad spot. Wolves are usually fearful of humans, but when they’re not, there is little that a lone, unarmed human can do to fend them off. Outrunning a wolf is impossible, as is, probably, winning a physical fight with a creature whose jaws can crush a moose femur. Your best bet would be to walk backward slowly, avoid eye contact, and pray.
If you were another wolf, however, you’d have much better options. One would be to exploit the Violence Inhibition Mechanism. Through it, you might be able to make the approaching wolf not want to attack you anymore. You’d need to start by avoiding eye contact and crouching down low. No, even lower. Your goal would be to try to look a fraction of your actual size. Even better, you might roll on your back, fold your legs in close to your body, flatten your ears, and emit a few whimpers—the higher-pitched and more helpless sounding the better. If you really wanted to go for the gold, and if the wolf came close enough, you could try licking the bristly underside of its jaws or peeing on yourself. If you have owned a very submissive dog before, you have probably seen these behaviors play out. If not, it all might seem distasteful and counterintuitive to you. Why signal how weak and pitiful you are to an animal that is threatening you?
Of course, you wouldn’t do any of these things if you were threatened by a nonsocial creature like a rattlesnake or a shark. Go ahead and try licking a rattlesnake and see where it gets you. But the social wolf is acutely attuned to signs that another member of its species is raising the equivalent of a white flag. In adopting postures and vocalizations that make itself look smaller and weaker, a wolf under attack can signal that it will not—cannot—contest its would-be attacker’s dominance and power, rendering an actual physical battle unnecessary. Weak and subordinate wolves display these cues all the time during conflicts with stronger, more dominant wolves, who largely inhibit their aggressive attacks in response. Such a system makes pack life better for everyone. Because they use body language and vocalizations to communicate their relative power and aggressive or non-aggressive intentions so effectively, wild wolves rarely resort to actual violence.
We humans may not pee on ourselves or roll onto our backs to signal fear and submission to one another, but we do have other cues that serve similar purposes. Body postures, vocal cues, and facial expressions that communicate dominance and subordination are built into our communicative repertoires just as surely as they are in wolves. And as is true for wolves, fearful and submissive cues tend to make a person appear physically smaller and weaker. Fearful body movements are cringing and crouching—think a hunched posture with shoulders huddled and hands and arms drawn in close to the body to shrink the visual silhouette. Fearful vocalizations are high-pitched, like the cry of a small creature with a small and minimally resonant larynx. And fearful facial expressions convey vulnerability and powerlessness through a combination of round, widened eyes, raised and upwardly angled brows, and a grimace. These cues are designed to appease—to literally disarm a potential attacker. Imagine hitting someone who was whimpering and cringing and looking terrified in front of you. It’s hard to contemplate without feeling like a terrible person. Consider your potential for Violence Inhibited.
James laid out how the Violence Inhibition Mechanism causes typically developing children to acquire an aversion to hurting others. Young children are almost always at least a little aggressive, with age two being the most violent year of a person’s life, statistically speaking. This, by the way, is another good argument against the idea that all aggression is learned. Most toddlers occasionally engage in reactive aggression, including punching, scratching, even biting, regardless of whether they have ever seen these behaviors modeled and without ever having been rewarded for them. Aggression is such a deeply rooted, primitive behavior that it doesn’t need to be learned. So, thanks to their violent propensities, young children eventually learn what happens when they hurt someone: that someone gets upset. When people get hurt, they cry or cringe or act otherwise distressed. And just as is true for wolves, these sorts of behaviors are fairly effective at terminating aggression in normal children. In one study conducted in the 1970s, researchers examined the behavior of young children forced to share a box full of gerbils—the elementary school equivalent of heroin—with another child. The researchers set the box down between each pair of children, said, “Go!” then hustled from the room. They were right to hustle, as 441 separate conflicts over the gerbils erupted during the study, which involved only 72 pairs of children.
The outcome of each conflict was recorded by the researchers, who discovered that one of the best ways for a child in possession of the gerbils to keep another child from grabbing them away was to adopt what are called oblique brows—the raised and upwardly angled brows that are a key component of both fearful and sad expressions. They look like this: / \. Oblique brows were a more effective gerbil retention strategy than any attempts to use logic (“My turn!” “I have to feed him!”) or physical force. Just as is true for wolves, the best way to resist attacks by gerbil-crazed six-year-olds is to use appeasement—to make them not want to attack.
The VIM has deterrent effects as well. As they develop and gain experience in social conflicts, children become able to predict in advance what sorts of behaviors will cause others to exhibit distress, and eventually they refrain from engaging in these behaviors with their peers. This is an essential part of the process of turning uncivilized toddlers into trustworthy members of their social group. The mechanism continues working throughout life. A recent study found that even during negotiations between adults, up to 12 percent more value can be accrued by a negotiator who expresses sadness as compared to anger or no emotion.
At least this is how things are supposed to proceed, but unfortunately, in a small percentage of children, the VIM doesn’t work. Approximately 7 percent of children, or about one in fifteen, will qualify for a diagnosis of conduct disorder at some point during childhood. Children receive this diagnosis when they persistently engage in behaviors that are violent or cruel or otherwise violate the rights of others. The occasional schoolyard fight or squabble over gerbils doesn’t count as conduct disorder. Children with this disorder threaten, bully, steal, and vandalize. They may set fires or engage in forcible sex. They are genuinely problematic.
Here are the full criteria for a conduct disorder diagnosis, according to the most recent Diagnostic and Statistical Manual of Mental Disorders (also known as DSM-5), published in 2013 by the American Psychiatric Association. Children with conduct disorder must have exhibited at least three of these fifteen criteria in the past year, with at least one criterion present in the past six months:
Obviously, any child who exhibits three or more of these behaviors is seriously troubled. But not all children with conduct disorder are troubled in the same way, or for the same reasons. Somewhere between half and two-thirds of children with conduct disorder exhibit primarily the reactive form of aggression. They are usually not deliberately cruel; rather, their fights and threats and destructiveness seem to be driven by fear or frustration. Importantly, they are also emotionally reactive after they act out. If they hurt someone or lose control, they may cry, wonder aloud what is wrong with them, or express unprompted remorse for what they have done. They seem genuinely sorry that their behavior may have hurt siblings or parents or friends they care about. These are the children for whom conduct disorder has most likely resulted from experiences of trauma or abuse, or perhaps an innately reactive or dysregulated temperament crossed with a moderately stressful environment. In these children, the Violence Inhibition Mechanism itself is probably intact, but its effects are sometimes overwhelmed by stronger forces. Focusing on these other forces, by either ameliorating sources of stress or trauma in the child’s environment or treating symptoms of depression, anxiety, or lack of impulse control with medication or psychotherapy often causes conduct disorder symptoms to abate as well. This outcome suggests that these children’s conduct disorder is a secondary diagnosis that is itself being caused by something else.
What about the other one-third to one-half of children with conduct disorder? For these 2 or 3 percent of all children, conduct disorder is not secondary to depression or anxiety. These children are, if anything, emotionally underreactive. Their aggression often isn’t accompanied by anger or upset—sometimes it seems to come out of nowhere, and to be purposefully cruel. Worse, it isn’t followed by any display of appropriate emotions like guilt or remorse in response to others’ distress. Being unruffled by signs of the distress that their cruel or violent behavior has caused others makes these children especially worrisome because it suggests that, for them, the Violence Inhibition Mechanism itself is impaired.
One reason these children may not respond appropriately to others’ distress is that they have trouble recognizing others’ distress. Specifically, as James discovered, these children show a deficit that is the mirror image of what I had found in my own work: the least empathic children are also the worst at recognizing facial expressions of fear. When shown images of frightened faces like the ones I used in my graduate work, or when played recordings of frightened voices, they fail to recognize the faces and voices as fearful, and they fail to show the same empathic responses to them that healthy children show, such as an increase in sweat on the palms of the hands.
And these are the children who are most at risk for becoming psychopaths.
I vividly remember the day I met my first such child. In 2005, another research group at the NIH called to tell us that a boy enrolled in their protocol might be a better fit for ours. The other group initially thought that simple mood dysregulation might be his main problem because he had frequent temper tantrums. But mood dysregulation alone doesn’t produce tantrums like Dylan’s.*
First, Dylan was twelve at the time, an age when, for most children, actual tantrums are in the distant past. Normally the preschool years are the ones that brew the most tantrums. And while a two-year-old’s tantrums may be annoying or frustrating, they are rarely significant problems. Now imagine an equally deranged tantrum produced by a boy who was five-foot-three and 120 pounds and able to reach every potential weapon in the house—knives, matches, baseball bats—and imagine it lasting an hour or more. Terrifying, right? That was Dylan. His bouts of rage would usually start over little nothings—irritation over not getting something he wanted or being punished for some misbehavior—and then quickly escalate, sometimes to red-faced screaming, other times to threatened or actual violence and destruction. During some of his worst episodes, he had threatened his parents with violence, punched or kicked holes in walls and doors, and, in one instance, smeared the walls of a room he’d been locked in with his own excrement. Once he threatened his mother with a knife. On that occasion and others, his mother brought his younger sisters to a relative’s house to spend the night for fear Dylan might actually follow through on his threats.
The details of Dylan’s tantrums provided our first clue that something beyond simple mood dysregulation was afoot. When a person has a tantrum, it sometimes appears that he has completely lost control and might literally be capable of anything, so helpless is he to counter the forces of the emotional maelstrom. But this is an illusion. Tantrums can actually be experimentally induced in laboratory animals like cats and monkeys by stimulating a region of the brain called the medial hypothalamus. The old-school technique was to insert a tiny electrode into this small, evolutionarily ancient structure and turn on the current. When electricity is sent surging through the medial hypothalamus of a cat, it can send the cat into a snarling, spitting, clawing rage that looks for all the world like a toddler having a tantrum—but only if there is another living creature in the cat’s environment. Rage, even electrically generated rage, needs a target. The same phenomenon has been demonstrated more recently using a much more precise technique, called optogenetics, in which the DNA of neurons is manipulated to make them fire in response to pulses of light. Then a tiny light-emitting optical fiber is embedded within the brain. When it is turned on, it will cause nearby genetically altered neurons to fire. Optogenetic triggering of neurons within the medial hypothalamus of a mouse will similarly cause it to launch coordinated, rageful attacks against other mice, or even against a wiggly rubber glove. But if the cage is empty when the light pulses—no aggression.
So even though a tree that falls in an empty forest will still make a noise, a child who trips and falls in an empty room will probably not throw a tantrum. What’s the point? Rage is an emotion designed to make things happen, usually by cowing someone else into submission (as the angry wolf did). This is probably why, among animals like monkeys that observe clear social hierarchies, electrically induced rage will not be directed at just any living target, but mainly at targets who are lower-ranking than the raging monkey. Higher-ranking monkeys, who are likely to be unimpressed by a subordinate’s rage attack, are usually spared. What does this mean? It means that even when an external machine is generating the rage attack—which would seem to be as uncontrollable as rage can get—the resulting behavior can still be modulated. The organism remains capable of maintaining some level of conscious or unconscious control over its behavior in accordance with basic biological rules—attack only living things, but not if they outrank you. This means that a child whose only problem is mood regulation will be very unlikely to go to extremes like threatening to stab his parents with a knife or smearing his own excrement on the walls, even in the grip of the most towering rage.
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 points 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 gash 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.
As we met more and more of these children and their parents, our ability to evaluate them continued to improve, although some cases were easier than others. Perhaps our most clear-cut case was Jamie, a sandy-haired, button-nosed twelve-year-old boy who bounced in, visibly crackling with energy and trailed by his kindly but beleaguered-looking mother. We always started out our interview sessions by talking to the parent alone. We would interview the child alone next, a sequence that allowed us to spot when a child was lying or glossing over misbehaviors. With Jamie, there was little need for this sequence. He couldn’t have been prouder to detail his many, many exploits to us. His misbehaviors ran the gamut. Other than the items related to serious crimes and sexual offenses, he received top marks across the PCL:YV. He stole things. He set fires. He lied. He charmed and manipulated. He constructed elaborate cons to bilk his schoolmates of their money or possessions. Despite only being in middle school, he was running a successful loan shark operation out of his bedroom in a wealthy suburb of Richmond, Virginia. Interest payments ran to a dollar a day. When payments ran late, Jamie threatened to shoot fireworks at his clients. Many of these clients were high school boys who must have towered over him, but they took him seriously. Among Jamie’s more florid exploits was the time he somehow procured an artificial grenade and lobbed it into his local public library, “just to see how people would react.” Not surprisingly, people reacted by fleeing the building. Crying, screaming children and their parents poured out in a panic. While everyone else ran away from the building, Jamie and his friend ran toward it—carrying a video camera, no less, the better to record the terror and mayhem they had caused for posterity. Jamie’s pride in his caper was obvious. “It was,” he concluded with a crooked grin, “a total Kodak moment.”
Jamie wasn’t our highest-scoring subject, though. That would be fourteen-year-old Amber. Amber panthered into our interview room oozing charisma and sexuality that made me, a thirty-year-old woman at the time, feel unsettled. I can only imagine what her effect on young boys and men was. She was fully aware of this. Like many of the girls we worked with, Amber had figured out that it was often easier to get what she wanted using charm and allure than threats or violence. Like anyone else, children with psychopathic traits use the tools available to them to get what they want. They just care less than others about the collateral damage those tools may inflict. Amber liked expensive clothes, for example, and older boys and men were the ones with the means to buy them, so she seduced them. She didn’t much mind that they would end up branded as sex offenders for life if they slept with her.
Amber had the highest intelligence score of any of our study participants, and it showed. In typical kids, a higher IQ tends to be associated with fewer behavior problems, but in children with psychopathic traits the opposite seems to be true—a higher IQ coupled with a psychopathic personality seems to lead to more serious offenses, perhaps because the combination yields a sort of canniness that helps them get away with ever-ascending misdeeds without getting caught. Amber was certainly preternaturally perceptive for a young teenager. I could feel myself being sized up throughout our interview—she watched our faces keenly as she fed us stories about killing the family’s pet guinea pig or threatening to burn down her family’s home while they slept. Like Jamie, she wasn’t trying to hide anything. Quite the opposite. She was happy to describe what was going on in her head during these exploits. She explained, for example, how she sized up adults to avoid being punished. “Some adults are impressed when I use big words,” she said. “Others will let me off if I cry.” Her mother confirmed that Amber could produce effective crocodile tears. Once, her mother had found in Amber’s bag a printout from the Internet titled “A Guide to Shoplifting,” along with a pile of cosmetics and an expensive handbag from an upscale department store. When confronted, Amber had burst into tears, protesting that she was sorry and she would never do it again. Her mother admitted that she’d been mollified by similar displays in the past, but was so galled by the brazenness of this incident that she snapped, “Oh, get real.” And Amber’s tears, she said, stopped like a switch had been flipped, replaced by Amber’s usual level stare. Amber was the only one of the children we tested with whom I would have been unwilling to spend a night alone in a house.
Not every child we talked to was so frank about their motivations and behaviors. Heather was among our most difficult subjects to evaluate. According to her father, she was a terror. Like Dylan, she threw wild, violent tantrums that sometimes went on for hours and left her limp and spent. She also engaged in proactive forms of aggression that were just subtle enough that she could claim she hadn’t been doing anything wrong. Her father suffered frequent migraines, and Heather went out of her way to slam doors and flip on bright lights whenever one of his headaches came on, seemingly getting a visible kick out of the pain these sensory assaults caused. She was sometimes violent at school, once striking a schoolmate with a toy with such force that he required stitches. And like many of our other study participants, she manipulated, lied, stole things, and lied about stealing things.
At least, according to her father all this was true. But when Liz and I sat down to talk to Heather, we were stunned by how differently she came across in person. Heather had the limpid brown eyes and long limbs of a doe, a sweet, shy smile, and a soft voice in which she told us stories that would begin in the same place as her father’s stories, but always ended up somewhere completely different—inevitably a place in which Heather had committed no wrongdoing. It was her father who had the terrible temper and was forever taking out his unhappiness on Heather (said Heather). And when the interview ended, I watched in amazement as Heather carefully cleaned up the wrappers and crumbs from the food she had been eating while we spoke. Liz and I emerged from the interview stumped. It was by far the biggest mismatch between a parent’s and a child’s stories we’d encountered. Even knowing how genuinely winning many of the children we met could be, it was hard to understand how Heather fit into our study. We ended up calling a referee—in this case, one of Heather’s teachers. We asked for details on several of the stories we’d heard two versions of that the teacher had personally witnessed, and in every case the teacher’s stories echoed those of Heather’s father. Heather was just an incredibly skilled deceiver—the best we ever encountered. If we had used just her interview, we would never have pegged her for one of the children we were studying. I could easily imagine having offered her a research assistantship or a babysitting position based on her interview. But when we tallied her up, she scored well above our cutoff. Yet another lesson learned.
I can guess what you’re thinking at this point. I have talked to many people about these children and their families over the years and tend to hear the same comments over and over. In some recess of your mind, the thought These kids must have really terrible parents may be bouncing around. The belief that badly behaved children are the product of bad parenting is so deeply rooted in our culture that it is difficult to dispel. But let me try. First of all, we acquired a lot of information about these families during the course of our screening and interviews, and while they varied in many ways, a common thread was that the parents had tried literally every possible option to help their children before coming to see us—counselors, medication, special schools, social workers. These were caring parents with resources who really were trying, but none of it helped. I’m not saying they all were the best parents in the world (they varied, naturally), but they were definitely not so bad that their parenting alone could have produced such children.
As evidence, nearly all of these parents had other children, most of whom we met, and none of whom were also psychopathic—much like Gary Ridgway’s normal siblings. If unusually terribly behaved children are the product of unusually terrible parents, then the children of such parents should uniformly be a mess, right? But they’re not. It’s not that poor parenting can’t result in badly behaved children—of course it can. But it doesn’t make children psychopathic. Parents who are overly permissive or simply unskilled may end up with ill-mannered or entitled or bratty children, but these problems can often be solved with a little coaching on setting clear limits and not rewarding misbehavior. And parents in highly dysfunctional households marked by domestic violence or neglect or abuse may produce children with significant behavior problems. But again, most of these children’s aggression tends to be of the emotional, reactive variety, and they often present with depression or anxiety as well.
When the misbehaviors are of the purposefully cruel, manipulative, deceitful, or remorseless variety, it’s a different story. Engaging in these kinds of behaviors seems to be much more strongly driven by inherited factors, as we know from adoption and twin studies. Recall that these studies consistently show that parenting and other environmental factors explain only a small fraction of the variation in the proactive aggression that psychopathic children engage in.
I should note that some recent studies examining the relationship between child psychopathy and parenting find that children with higher levels of psychopathic traits have parents who are colder or more neglectful than average. The urge to assume that the arrow of causation runs in a straight line from cold and neglectful parents to callous and remorseless children is a powerful one. But there are several alternatives. One is that cold and uncaring parents end up with cold and uncaring children because they share similar genes that predispose them toward this personality profile. More than one adoption study suggests this is true. Another alternative is that a child who is difficult from the get-go causes his parents to become colder, less attentive, quicker to punish, and harsher when they do, a dynamic also backed up by research. These various causal pathways may of course interact as well, such that different styles of parenting may buffer or exacerbate the expression of psychopathic traits. For example, some recent research suggests that very high levels of parental warmth may lessen the severity of inherited psychopathic traits. So although cold parenting does not cause children to become psychopathic, interventions focusing on increasing the warmth of parents’ interactions with their children may help to reduce symptoms, particularly in younger children.
The parents of the psychopathic children we studied, however, had never had any of these nuances explained to them. Instead, everyone from pediatricians to school principals to neighbors had placed the blame squarely on them and their putatively rotten parenting. They often blamed themselves as well, being subject to the same cultural forces as the rest of us. More than one parent became teary when we asked if they thought their son or daughter ever felt remorse for any of the things they’d done. When I asked Michael’s mother this question, her face crumpled. After a long silence, she responded, “I want to think he does, but…,” then trailed off.
What could I say? She was right. He didn’t care. Many days my heart ached for these children’s parents long after I left the interview room.
So what was going wrong with these children? Our goal was to find out using the (at the time) fairly new technology called functional magnetic resonance imaging (or fMRI for short) to peek inside the active brains of these children. The emergence of fMRI in the 1990s revolutionized the field of cognitive neuroscience, which aims to identify biological mechanisms that undergird mental processes like attention, memory, and emotion. Before the emergence of fMRI, researchers who wanted to identify a malfunctioning brain area in a clinical population had only a few choices. One was to use positron emission tomography (PET), which requires injecting study volunteers with a radioactive sugar solution, then hustling them into a PET scanner before the radioactive isotopes decay. The end result is fairly fuzzy images of energy consumption levels inside the brain. Or, if researchers suspected that the problem lay in some dysfunction in the brain’s cortex, right underneath the skull, they could use electroencephalography (EEG) to measure electrical potentials across the scalp. But, like PET, the readings produced by EEG are spatially fuzzy, making it hard to tell exactly what part of the brain is generating the signal.
Although both PET and EEG are valuable, fMRI opened up new worlds to cognitive neuroscientists, permitting direct and spatially precise measurement of activity deep inside the brains of living, behaving humans. An MRI scanner is just a giant, doughnut-shaped magnet; fMRI is the use of such a magnet to detect small increases in the flow of blood to brain areas that are active and clamoring hungrily for the fuel that blood carries. Unlike a PET scan, an MRI scan uses no radiation, although it does have other limitations, which mainly stem from the fact that fMRI measures blood flow rather than activity in neurons themselves. Measuring blood flow limits the temporal precision of fMRI because the ebbing and flowing of blood in the brain (termed the hemodynamic response) takes a few seconds, whereas changes in actual neural activity take place in milliseconds. On the other hand, fMRI’s spatial precision is good and getting continually better as stronger magnets and more advanced software are rolled out. The MRI machine we initially used at NIMH in 2004 was a 1.5-Tesla magnet, which is about 50 percent stronger than the magnets that lift cars in scrapyards. Later we switched to a 3-Tesla magnet, which is standard today. Recently, the NIMH acquired a 7-Tesla magnet, which is so powerful that it can measure changes in brain activity with a spatial resolution of one cubic millimeter—although it wreaks such havoc on charged particles in the inner ear that volunteers must be rolled into its bore very slowly to avoid getting vertigo or vomiting. I had the occasional bout of dizziness working next to the 3-Tesla magnets, but the sensation wasn’t unpleasant, just strange (and not nearly as distracting as its sly tugs on the metal hooks and rings of my bra).
We would be using fMRI to measure activity in parts of the brains of psychopathic teenagers that are hard to assess using any other approach, in particular the underside of the prefrontal cortex, which sits right above the eyes, and a region called the amygdala. The amygdala (Latin for “almond”) is a lump of fat and fiber about half an inch in diameter that is buried beneath layers of cortex under each temple. The structure is so small and lies so far beneath the scalp that neither PET nor EEG can reliably measure its activity. But its small size belies its importance. Among other things, it plays a critical role in recognizing fearful facial expressions.
This had first been discovered in 1994, prior to the advent of fMRI, through neurological studies of a patient with a very rare kind of brain damage: total obliteration of both the left and the right amygdala, and nothing else. No accident or stroke can do such precisely localized damage; instead, the culprit is a rare genetic illness called Urbach-Wiethe, which can cause the amygdala to gradually calcify over the first decade or two of a person’s life. In the late 1980s, a group of researchers, led by Daniel Tranel at the University of Iowa, was approached by a woman with this condition, whom they called S.M. to protect her privacy. S.M. was twenty at the time, with a pleasant, open face, a breathy voice, and a flirtatious, disinhibited demeanor. She liked to stand about twelve inches away from the person she was talking to, and the researchers’ first published description of her drily described her “tendency to become somewhat coquettish” during her testing sessions. A CAT scan of her brain confirmed that her amygdalae were totally destroyed. Intrigued, the researchers ran S.M. through dozens of cognitive tests to see what else she’d lost along with this structure.
Many of her mental abilities remained intact, including her intelligence and memory, but among the deficits the researchers uncovered was S.M.’s inability to recognize others’ fear. The researchers presented her with a series of emotional facial expressions, including some of the same ones I’d used in my research, and asked her to provide a label for each. She had no trouble with faces that expressed anger or disgust or happiness or sadness; her performance corresponded very well to that of other adults, including adults with damage to other parts of their brains. But when she was shown photographs of people who looked frightened, she bottomed out, describing the expressions alternately as sad, disgusted, angry—nearly anything but fearful.
The researchers wondered what S.M. thought fear did look like, so they asked her to try to draw a frightened face, along with faces expressing other emotions, a request that revealed her knack for portraiture. Her depictions of anger, sadness, and disgust were vivid and easily recognizable. The angry face glowered fiercely, looking a bit like a bearded Fidel Castro in his prime. Tears dripped from each eye of the sad face, the eyebrows of which were perfectly oblique. But when asked to draw a fearful face, S.M. literally drew a blank. She protested that she had no idea what it would look like—no image at all came to her mind. She tried several times to create drawings that she ended up scrapping. Finally, she produced an image that looked nothing like the others. It was not a portrait, but a small, round figure shown in profile on its hands and knees. Its expression was hard to read, but it did not look frightened. Its mouth was closed, and its brows sat low and straight over its eyes.
Subsequent tests of other individuals with localized damage to the amygdala have consistently revealed similar patterns—their ability to recognize fearful facial expressions is reliably impaired. The most recent such study found fear recognition deficits nearly identical to S.M.’s in a teenage Urbach-Wiethe patient in Iran. Such patients sometimes have trouble recognizing fear from other cues as well, including vocal utterances, body postures, even emotionally stirring music. Damage to no other brain structure results in this specific pattern. These data make clear that the amygdala must play some important role in our ability to recognize expressions of fear.
Strikingly, they also point to the conclusion that psychopathic children’s struggle to recognize others’ fear may similarly stem from dysfunction in their amygdala.
To determine whether Dylan and Amber and Michael and the other adolescents we were recruiting in fact suffered from amygdala dysfunction, we needed to measure activity in this structure while they viewed fearful facial expressions. Viewing fearful expressions generally produces a robust amygdala response in healthy people. Hundreds of studies have now been conducted examining healthy adults’ brain responses to facial expressions using fMRI, and this is what they reliably show. The amygdala is more active when people view fearful expressions than when they view any other expression—backing up what studies of S.M. and other Urbach-Wiethe patients suggest, which is that the amygdala plays some special role in processing this expression.
So every time we interviewed a newly recruited adolescent for our study, Liz and I would race back to score their PCL:YV and sign up those who were eligible for a brain scan as soon as possible. Speed was imperative. We were always in a race with the unknowable, unpredictable disasters that tail kids with psychopathic traits. More than one child who cleared all our screening hurdles—getting a conduct disorder or oppositional defiant disorder diagnosis, demonstrating a normal-range IQ, receiving high psychopathy scores—became unscannable soon afterward. Several ended up hospitalized or in detention. A few of the girls got pregnant. Occasionally parents threw in the towel and sent their children to live with another relative who might be better able to manage them. We thought we were in the clear on our first attempt to scan a boy named Derek, as his scan was scheduled only a week after his interview, only to have him lope in on scanning day wearing a bulky, metal-laced monitoring bracelet on his ankle that had definitely not been there before.
“What is that?” I asked in a panic.
“It’s my monitoring bracelet,” he said. “I just got it.”
“Um… I don’t think we can put you in the scanner wearing that, Derek.”
“No, no, no, no. Please don’t do that!” I hastened to say. “Why don’t you just come back after it’s off?”
Although MRI technology itself is quite safe, the presence of magnetic metal inside the scanning room can be catastrophic. Rarely, people have been injured or killed when loose metal oxygen tanks, scissors, or other objects were accidentally brought too near the magnet. These objects can be pulled into the bore with such force that they essentially become cannonballs in reverse, with dire consequences for anyone who happens to be inside. Even metal affixed to a person isn’t necessarily safe. A firefighter once got sucked into an MRI via the metal oxygen tank strapped to his back. He ended up pinned inside the scanner with his knees pressed so hard against his chest that he was on the verge of suffocating by the time someone quenched the magnet. The metal checks we gave each child before a scan were the stuff of a TSA supervisor’s dreams. Pockets were emptied, hair was checked and rechecked for pins and clips, jewelry was removed—even shoes, which sometimes contain a metal shank, had to come off. How quickly I came to loathe cargo pants, with their dozens of tiny pockets caching forgotten keys and safety pins.
We nearly had to cancel one scan when a subject named Brianna arrived wearing a new nose ring that she didn’t know how to remove. Putting her in with the ring was not an option. It was a great, fat steel thing, and the scanner could have torn it right through her nostril. But as luck would have it, we were running two scans that day, right next door to each other, and the other participant was Amber, who had ample experience with piercings and who offered to help when she heard Liz and me conferring.
I remember looking at Liz in alarm. I knew what both girls were capable of. They were two of our most violent participants. I half expected that just being in the same room together would cause them both to explode, like matter and antimatter colliding. But we really wanted to scan Brianna before anything else came up. (As it happened, she became pregnant not long after.) And it wasn’t like there was an explicit rule against letting participants take each other’s piercings out. True to form, they were very polite with each other. I held my breath as I watched Amber unscrew the ball at the end of the nose ring and thread the ring carefully through Brianna’s nostril. “Here you go!” she said, dropping the slightly damp ring into my palm. It was a sign of how grateful I was that it never occurred to me to be grossed out.
So, thanks to Amber, into the scanner went Brianna. Later, in went Amber. Dylan and Michael and Jamie and other teenagers like them followed. Inside the scanner, each watched through a mirror as a series of black-and-white fearful, angry, and neutral facial expressions flickered across a projection screen. I would love to know what was going through their minds as they watched. In many fMRI tasks, this is a critical question. If a participant spends the scan wondering what the task is about, the scan will be ruined—unless the researchers are trying to measure the brain activity associated with “wondering.” We were running what is called a passive viewing task. Emotional facial expressions are such primitive stimuli that people don’t need to consciously focus on them for their brains to respond. As long as their attention doesn’t get too derailed, it’s actually better if they don’t focus on what the emotion is. The simple act of labeling an emotion, whether your own or someone else’s, is actually a mild form of emotion regulation and can reduce the affective response to it. So we asked our participants to label the gender of each face instead. For over twenty minutes at a stretch, each child lay there pressing buttons to categorize over a hundred grimacing faces as male or female. It was such a deeply boring task that it’s a wonder any of them finished it. Did I mention that they had to lie perfectly still the entire time? As little as four millimeters of movement—even just a jiggling foot—could render a scan unusable. Thank goodness we could pay them. Even a child with serious behavior problems can (usually) handle twenty minutes of stock-still boredom if $75 is waiting on the other side.
For years Liz and I spent every other Sunday under the glare and buzz of the fluorescent lights in the NIH basement collecting MRI scans of these children, as well as scans of matched healthy control children to whom we could compare them. All this work was of course in part aimed at reaching our own goals—our findings ultimately were published in prestigious psychiatry journals, which helped us later attain faculty positions, research funding, and invitations to conferences. But we were also strongly motivated by the broader gains our work could yield. Our studies were the first effort to directly measure brain dysfunctions that might contribute to psychopathic traits in children and adolescents and would represent an important step toward understanding the roots of psychopathy, which might lead to better ways of identifying and treating such children in the future.
Such steps are desperately needed. Children with conduct disorder and oppositional defiant disorder are every bit as mentally ill as children with bipolar disorder or anxiety or autism, but much less is known about the origins of their disorders because only a tiny fraction of available public and private research resources are devoted to understanding them—far, far less than the resources spent on relatively less prevalent and severe disorders. Given this, it’s a small wonder that so few effective therapies—either pharmaceutical or behavioral—exist to treat them. This fact makes life worse for everyone: certainly for affected children and their families, but also for their friends, teachers, and other community members whose lives are negatively affected by the untreated aggressive and disruptive children in their midst. Despite how difficult and occasionally dispiriting it can be to study these children, the urgent need of these children and their families and communities remains a constant motivator.
At last we collected usable data from twelve non-pregnant, non-institutionalized, non-jiggly children with psychopathic traits and twenty-four matched controls (twelve of whom were healthy and the other twelve of whom had only ADHD). Subsequent analyses of the data took weeks because of the enormous amount of information that a whole-brain fMRI scan collects and the number of transformations the data must be subjected to before they can be analyzed. At the end of this long process, I finally conducted the statistical test comparing activation in the amygdala across the three groups of children while they viewed fearful expressions. When the analysis finished running, I opened up the image that would show me whether our hypotheses were confirmed: whether children with psychopathic traits fail to show appropriate elevations in amygdala activity when looking at these expressions. I scrolled through the image, the whorls of the cortex unfolding as my cursor moved deep into the temporal lobe, holding my breath until I got to the amygdala, hoping that it would show a cluster of differential activation—and there it was! A little glowing red blob signifying differences in activity across the groups of children, right where it should be.
On average, our psychopathic children showed no activation—zero—in the right amygdala when they viewed the face of someone experiencing intense fear as compared to a neutral face. The sight of another person in distress made no mark on this part of their brains. This was quite unlike what we saw in the healthy children and the children with ADHD, who, on average, showed reliable increases in amygdala activity, just as most adults do. Our finding, which has now been reproduced several times by researchers from different laboratories, helps explain why children with psychopathic traits have so much difficulty recognizing fear in other people—why the sight of the distress that their violence and threats cause others has so little power to inhibit their cruelty. It is because the region of the brain that is critical for accurately identifying and responding to these expressions is defective; as a result, these children literally struggle to understand what they are looking at.
More insight into this pattern of results emerged from the results of one of the cognitive tests that Liz and I had also been conducting with the children along the way. The test was aimed at evaluating the children’s subjective experiences of different emotions. First we asked the children to recall times in their lives when they had experienced strong emotions themselves, including anger, disgust, fear, happiness, and sadness. Next, they were to describe details of each event and how it made them feel, in terms of both body sensations and psychological experiences. People who are psychopathic are known not to show strong physiological responses, like changes in sweating and heart rate, in response to images or sounds that most people find frightening. But no one had yet systematically inquired whether children with psychopathic traits feel fear psychologically in the same way as other children. As we discovered, they don’t.
Overall, the children with psychopathic traits reported that they felt fear only infrequently and weakly. When asked, for example, how often they felt fear on a scale from 1 to 7, the average response for healthy children was a little over 4. Michael and Amber both circled “1” (“never”). Their responses echoed the stories we’d heard during our interviews. Michael was forever hurting himself when attempting physical stunts like riding his bicycle off the roof of his school; Amber’s mother recounted in wonder that when Amber was in preschool she would sometimes run off and her mother would find her playing alone in the pitch-dark, spooky basement of their building. Some of the children with psychopathic traits reported that they had felt fear when, for example, they found themselves on a roller coaster that got stuck, or saw a falling tree narrowly miss their house during a hurricane. But when we queried them on how this fear felt, they reported not feeling the same intense physical changes as the healthy children, like muscle tension, shaking, or breathing changes. Two of the psychopathic children we queried claimed that they had never felt fear in their entire lives, whereas no healthy children said this.
This might be my favorite response to a question about fearfulness in the children I’ve worked with. This child, a thirteen-year-old girl, embellished her response to a survey question about fear with the comment: “(Nothing scares me!) #Nothing”:
The response of a thirteen-year-old girl with psychopathic traits and serious conduct problems when asked to indicate whether she agreed with the statement “What scares others doesn’t scare me.” She checked off “applies very well,” and so that there would be no mistake about it, added, “(Nothing scare’s me!) #Nothing.” Abigail Marsh.
We didn’t find the same pattern for any of the other emotions we asked about, all of which psychopathic and healthy children generally reported experiencing in similar ways. Ours was not the only study to find these effects; several other labs have since produced similar findings confirming that psychopathic children show drastically muted physiological and subjective fear responses.
These findings also beautifully parallel previous findings in S.M., who similarly shows no physiological or subjective fear in response to things that most people find scary. Even attempts to induce extreme fear in her by taking her through a haunted house or handing her pet snakes have yielded no fear response at all—only curiosity. Similar fearlessness has been observed in other patients with severe amygdala lesions, as well as in animals whose amygdalas have been experimentally lesioned. It appears, then, that amygdala damage, whether in association with psychopathy or as a result of Urbach-Wiethe, can result in two unusual and specific impairments: difficulty recognizing others’ fear, and a muted personal experience of fear.
To me, this suggested a possibility that goes somewhat beyond what the VIM model and other models of psychopathy propose, which is that amygdala dysfunction in psychopaths impairs not only their behavior but their fundamental ability to empathize with others’ fear.
It is widely agreed that an intact amygdala is important for coordinating the array of physiological and subjective processes that result in the experience of fear. This is not the amygdala’s only role by a mile, but it is one of its core functions. When an external threat is detected, the sensory cortex conveys detailed information about the nature of that threat to your amygdala: Is it a snake? A gun? The edge of a cliff? The amygdala—which has been described as the most densely interconnected structure in the cerebrum—then rallies the neuronal troops to respond. Messages are conveyed to ancient subcortical brain structures that govern low-level behavioral and hormonal responses to any danger, like the hypothalamus and the brain stem. These structures dutifully ratchet up your heart rate and blood pressure, maximize your air intake, rev up adrenaline production, drive blood into your muscles and away from your core, even pump sugar into your bloodstream for energy. The amygdala also conveys information about the specific threat to various regions of the cortex that enable you to register that a problem has been detected and to alter your ongoing behavior to prevent injury. Without an intact amygdala, none of these processes work very well. The various independent regions all still work, but they cannot be marshaled in the same coordinated way in response to danger.
More, it is thought that the amorphous subjective feeling of fear somehow emerges from the confluence of all this coordinated brain activity, and that too is largely lost in both amygdala lesion patients and highly psychopathic individuals. As one psychopathic sex offender interviewed by the renowned psychopathy researcher Robert Hare responded when asked why he failed to empathize with his victims, “They are frightened, right? But, you see, I don’t really understand it. I’ve been scared myself, and it wasn’t unpleasant.”
I think we can agree that this is not the statement of someone who really understands what it means to feel fear.
And if someone doesn’t understand what it means to feel fear, how can they possibly be expected to empathize with this emotion in others? In fact, as our accumulated data suggested, they can’t. Without a normally functioning amygdala, psychopathic adolescents—and presumably adults as well—don’t recognize others’ fear for what it is, they don’t understand how a frightened person is feeling, and they don’t, as a consequence, appreciate what is wrong with making someone feel this way. More recent studies I have conducted with my student Elise Cardinale show that, unlike most people, those with psychopathic traits think it is fine to cause others fear by using threats like, “I could easily hurt you,” or, “You better watch your back.” In an fMRI study, we demonstrated that these aberrant judgments correspond to reduced amygdala activity as these individuals arrive at their judgments.
When Amber hissed threats of arson and violence at her parents, when Dylan held up a knife to his mother and threatened to cut her, when Brianna vowed to beat her schoolmates to a pulp, they did so because they had learned that threatening violence was a useful tool that would help them get their way, but they had no deep appreciation of the emotional suffering these threats caused. Dysfunction in the amygdala and the network of brain regions to which it’s connected had robbed them of an essential form of empathy, which is the simple ability to understand another person’s experience of fear. They might have had difficulty labeling the emotion their threats caused as “fear,” and they almost certainly would not have been able to accurately describe how it felt or truly understand why it was wrong to cause it.
* To protect the anonymity of individual participants, case study details have been combined to create composites, and names and identifying details have been changed.