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The Moral Brain: Psychopathology
This chapter considers two systems that are fundamental to human behavior: learning and the allocation of attention. We review the evidence to suggest that there may be deficits in these systems in a subset of children with antisocial behavior problems—those with high levels of callous-unemotional traits—and explore how altered function of these systems might contribute to the development of immoral behavior.
Viewing immoral behavior through a developmental lens helps to demystify adult perpetrators and provides a mechanism by which small and subtle differences in cognitive function can, over time, interact with environmental factors to interfere with the development of moral behavior.
Morals can be violated by anyone of any age. Children can often be purposefully immoral and intentionally cruel. Indeed, behaviors demonstrated by toddlers are frequently immoral; toddlers are generally self-focused and unconcerned with the effects of their behavior on others. Very young children are, essentially, driven by their own desires and their own needs, having not yet developed the cognitive capabilities, or theory of mind, to understand that their experience of the world is not shared by everyone else. As the understanding that other people have different experiences, thoughts, and feelings develops, so too does a child’s ability and inclination to consider other people and to adapt his or her behavior toward social and moral standards. It is the failure of this development that appears in a large part to characterize the forms of psychopathology that we associate with moral dysfunction.
So, the question underlying the etiology of immoral behavior really asks why normal development fails. Why do some people learn to stop breaking moral rules in childhood and others continue to do so well into adulthood? This chapter focuses on psychopathologies of immoral behavior from a developmental perspective: which psychopathologies of childhood are associated with a lack of moral development, and what are the cognitive and emotional processes that drive these disorders?
Psychopathologies Associated with Immoral Behavior
The psychopathologies of childhood most strongly associated with immoral behavior are oppositional defiant disorder (ODD) and conduct disorder (CD). These disorders are relatively common; around one in every twenty children (at least one child per classroom) will meet diagnostic criteria for ODD or CD. ODD describes a pattern of defiant behaviors that can include anger and hostility, disobedience, temper tantrums, and spitefulness and that occur more frequently than would be typical for the child’s age and cause serious and significant impairment in the child’s life and for that child’s parents, teachers, siblings, and peers. The criteria for CD includes behaviors that demonstrate more serious antisocial behaviors and violations of others’ rights, such as violence and aggression, physical cruelty, destruction of property, deceitfulness, and theft.
Impulsivity and Emotion Dysregulation
Children diagnosed with ODD or CD often display difficulties with impulsivity and emotion regulation. These children may be described as “hot-blooded”; they are quick to get angry or upset in situations in which they then act without thinking of the consequences. These children express remorse and regret when they have lost their temper and have done something wrong and may be frustrated and upset by their own lack of ability to control their behavior. Although impulsivity and emotion dysregulation are the most common features of antisocial behavior in childhood, and indeed in adulthood, they are not addressed in this chapter. The reason for their exclusion from a discussion of psychopathologies of morality is that they are not, in and of themselves, specific to immoral behavior—impulsive children are as likely to be impulsively prosocial as they are antisocial. There are, however, some children (and adults) who appear to engage in antisocial acts not because they fail to control their impulses but because they simply desire to do so. It is these people, and the processes underlying their behavior, that are the focus of this chapter.
Callous-Unemotional Traits
Children with antisocial behavior problems such as ODD or CD may be characterized by the types of personality traits we associate with psychopathy. Psychopathy is generally considered as comprising two main factors. The first factor concerns features of personality and interpersonal style including diminished guilt and remorse, the manipulation of others, a shallow affect, superficial charm, and a lack of empathy. The second factor concerns antisocial behaviors and lifestyle factors such as irresponsibility and juvenile delinquency. Factor 1 traits—aspects of personality—vary normally within the general population and may not always be accompanied by factor 2 behaviors.
In children and adolescents these factor 1 features of personality are referred to as callous-unemotional (CU) traits, and they have been introduced into DSM-5 as a specifier to the diagnosis of conduct disorder. It is too early to say whether CU traits in childhood are the same traits with the same etiology as psychopathic personality traits in adulthood. However, it has been demonstrated that the occurrence of high levels of CU traits is a marker for a particularly severe and chronic course of antisocial behavior. Furthermore, there is growing evidence that CU traits are associated with poor response to current interventions for antisocial behavior problems. Frick, Ray, Thornton, and Kahn, 2014 (2014) identified twenty studies comparing outcomes of treatment for youth with and without CU traits, eighteen of which reported poorer outcomes for youths with CU traits. This finding has been replicated in samples ranging from early childhood through adolescence and is evident when controlling for baseline severity of behavior problems. Thus, it appears that CU traits interact with the mechanisms of change through which these interventions operate.
Evidence also shows that there is a strong genetic component to both CU traits (Viding, Jones, Paul, Moffitt, & Plomin, 2008) and psychopathic personality traits (Beaver, Barnes, May, & Schwartz, 2011). Research has implicated a number of neurochemical systems in the etiology of psychopathy including, but not limited to, the serotonin system and the oxytocin system; and abnormalities in the function of specific brain regions such as the amygdala and ventromedial prefrontal cortex have been linked to psychopathy and CU traits (see Blair, 2010, for a review). As research suggests that CU traits and psychopathic traits have similar genetic and neurological correlates, it is understandable that CU traits are often considered the developmental analogue of psychopathy.
The Development of Callous-Unemotional Traits
So, why do some children develop CU traits? What causes them to become vindictive, manipulative, and seemingly emotionally cold? It is a difficult question, and its complexity allows it to be addressed from a variety of angles. Philosophers might question whether people are born “evil”; theologians may query the role of God; criminologists may look to the family environment; and sociologists may point to the social context. So, what if we were to simplify the question? For example, why do some people put their hands in front of their mouth when they sneeze and others don’t? It is not an instinctive reaction; babies do not do it. Why then is it so commonplace? From a psychological perspective, the answer is simple: we are taught to do so. During early childhood a parent or a teacher will have repeatedly reminded the child to cover his or her mouth when they sneeze. The child may have been chastised for not covering his or her mouth. An inquisitive child will have asked why it is important and will have been told about germs and how stopping the passing on of those germs is a considerate thing to do. Perhaps that child also saw the expression of disgust on someone’s face when he or she was sneezed on. Maybe the child him- or herself disliked the sensation of receiving a full-force sneeze in the face. It is likely that, together and over time, all these scenarios have developed the child’s response to cover his or her mouth when a sneeze was imminent.
What if we were to learn more complex moral behaviors in the same way? What processes are required? If we look back at our example of sneezing, then two fundamental processes stand out. First, the child must be able to learn, that is, to form an association between one thing and another. The child must have been able to associate being told off with not putting her hand in front of her mouth and to associate being praised with putting her hand in front of her mouth. The child must also have been able to associate the action of sneezing—without a covering hand—with other people’s facial or verbal expressions of disgust or anger. Without these very simple associations, appropriate new behaviors cannot be learned—children would just experience the world as one in which they sneeze and that, independently of this, sometimes they are praised, sometimes they are told off, and sometimes people get angry or disgusted with them for no apparent reason. It is the association between the child’s behavior and the reaction of others that allows consistent behavior change to occur. Presuming that the child enjoys being praised, dislikes being chastised, and feels bad when other people get angry or upset with him, the child will adapt his behavior so as to maximize praise and minimize punishment. In other words he will learn to cover his mouth when he sneezes.
The second process that is fundamental to behavior change is the allocation of attention. What if, when the child sneezed in the face of her parent, the child failed to notice the look of anger and disgust displayed on the parent’s face? What if the child failed to see her parent wipe the spittle from her face? What if the child only paid attention to the verbal reprimand? And what if that reprimand was not specific such as: “Eurgh, that was disgusting. Don’t do that!”? Then, how does the child know that she is being chastised for not covering her mouth rather than just for sneezing in general? Without the appropriate allocation of attention, social cues are missed, and the specific features of association formation can be lost.
It is easy to see how a child with deficits in learning and in the allocation of attention may fail to learn how to appropriately control a sneeze. But, surely a child with such profound deficits would stand out? Wouldn’t he struggle in school and have severe developmental delay? Children with antisocial behavior problems and high levels of CU traits are not typically characterized by developmental delay (Allen, Briskman, Humayun, Dadds, & Scott, 2013). Similarly, adult psychopaths are not known for having learning difficulties or below-average IQ. Despite this, both adults with high levels of psychopathic personality traits and children with high levels of CU traits have been shown to have subtle yet distinct deficits in both associative learning and attentional processes that point to a neural basis for the development of psychopathy (see Moul, Killcross, & Dadds, 2012, for a review). The remainder of this chapter considers how deficits in these two processes manifest and how they might contribute to the development of psychopathic personality traits.
Deficits in Associative Learning
Individuals with high levels of psychopathic personality traits show no deficiencies in the ability to form an association; that is, they are able to learn that a response to a certain stimulus results in a particular outcome. A psychopath’s deficit in associative learning is, however, very subtle. Imagine a scenario in which a response to a given stimulus has, every time you have encountered that stimulus, resulted in a certain outcome. Pressing the spacebar on your computer keyboard, for example, has always resulted in a space appearing in the text you are typing. An association has been formed between the spacebar (stimulus) and a space appearing in your text (outcome) each time the spacebar is pressed (response). Now, imagine a scenario where, unbeknownst to you, a virus has infected your computer. Now, when you press the spacebar, the last letter you typed is deleted—the outcome associated with the stimulus has been changed. Most people may press the spacebar one or two more times before ceasing to do so—as they fear that continuing to press the spacebar will delete more of their work. In contrast, someone with high levels of psychopathic personality traits is more likely to continue pressing the spacebar for longer even though the outcome associated with the action is deleterious. Experimentally, it has been reliably shown in a variety of tasks that psychopaths are poorer at updating their responses as a result of changing outcomes associated with a stimulus. Tasks of passive avoidance, for example, have demonstrated that people with high levels of psychopathic traits will continue to select a stimulus (rather than not select it) when that stimulus was originally paired with a positive outcome but has since become paired with a punishing outcome (e.g., Newman, Patterson, Howland, & Nichols, 1990). Psychopaths show an analogous deficit when two stimuli (e.g., a red button and a yellow button) are presented simultaneously. In these “response-reversal” paradigms one button is associated with a reward (winning points) while the other button is associated with a loss or punishment (losing points). Both psychopaths and nonpsychopaths quickly learn to press the rewarding button and to not press the punishing button at the start of the experiment. In a typical response-reversal paradigm, at a point during the task, the outcomes associated with each button swap over so the rewarding button becomes punishing and the punishing button becomes rewarding. Nonpsychopaths quickly learn to alter their responses accordingly—they will press the button that is now rewarding but that was previously punishing and avoid pressing the button that used to be rewarding but is now punishing. Just as in tasks of passive avoidance, as compared to nonpsychopaths, psychopaths take significantly longer to appropriately alter their responses once the switch in outcomes has occurred (e.g., Budhani, Richell, & Blair, 2006).
To take a real-world example, imagine a boy with high levels of CU traits who is making his friends laugh by doing a comedic impersonation of a classmate. Perhaps when the boy first does the impression, the classmate he is mimicking finds it funny and laughs along with everyone else. After a while, however, the classmate starts to feel embarrassed and gets upset at the continuing impersonation. Another child might quickly notice this and stop the impersonation to save the classmate’s feelings, but the boy with high levels of CU traits is insensitive to the change in the outcome (the classmate’s response changing from laughing to sadness) and so continues to embarrass his classmate in front of his friends. He becomes, albeit inadvertently, a bully.
Deficits in the Allocation of Attention
The allocation of attention also plays an important role in learning. Attentional deficits have been demonstrated both in adults with high levels of psychopathic traits and in children with high levels of CU traits. As with deficiencies in associative learning, the problems with the allocation of attention demonstrated by psychopaths are subtle. For example, one of the most reliable findings in psychopathy research is that of a reduced conditioned-fear response.
Fear-Potentiated Startle
Normally, if a neutral stimulus (e.g., a tone) is consistently paired with an aversive stimulus (e.g., a loud noise) then the neutral stimulus becomes predictive of the aversive stimulus. Thus, when the neutral stimulus is presented, the animal expects the aversive cue to follow and is made to feel fearfully expectant. If the aversive stimulus does then occur (the loud noise plays), the animal displays a fear-response that is more exaggerated (conditioned-fear response) than if the aversive stimulus (the loud noise) had occurred in the absence of the cue (unconditioned fear-response). It has been reliably demonstrated, however, that psychopaths fail to show this fear-potentiated startle response (Newman, Curtin, Bertsch, & Baskin-Sommers, 2010), although they do demonstrate normal unconditioned fear responses (Birbaumer et al., 2005).
Interestingly, it has recently been shown that this deficit in the conditioned-fear response in psychopaths is moderated by attention. Newman et al. (2010) found that under conditions in which participants were instructed to focus on nonpredictive aspects of the stimuli, adult psychopaths demonstrated a reduced conditioned-fear response that replicated previous findings. However, when the participants were told specifically to attend to the fear-relevant features of the stimuli, the psychopaths’ deficit in the conditioned-fear response normalized. Importantly, the psychopaths were able, before the instructions to attend to the relevant features of the stimuli they were given, to identify which feature of the stimulus was predictive. Consequently, the manipulation served only to direct their attention and did not alter their knowledge of the relationships between stimuli.
Emotion Recognition
The allocation of attention has also been demonstrated to be important in the accurate recognition of emotions. Both adult psychopaths and children with high levels of CU traits show deficits in emotion recognition, most reliably in the recognition of fear (see Marsh & Blair, 2008, for a meta-analysis). Compared to people without high levels of psychopathic traits, those with high levels of psychopathic traits are more likely to incorrectly label a face expressing fear as expressing a different type of emotion. Fear is the only main emotion in which the meaning of the expression is expressed by the eyes only. Fearfully widened eyes are the key feature of a fearful face. Indeed, there is an evolutionary argument for why the eyes are the key to a fearful expression. The expression of fear is more than just a portrayal of an emotion; it is also a very efficient and important method of communication. If someone is expressing fear it is likely that there is a considerable threat in the near vicinity. In order to determine where this threat is coming from and so enable you to run in the opposite direction, all you have to do is look to see where the gaze of the fearful person is directed. In this way the expression of fear communicates information that would have been critical to our survival in the early evolution of our species.
It has been shown that psychopaths and children with high levels of CU traits exhibit a deficit in the ability to correctly identify fearful faces unless their attention is directed toward the eye region of the fearful face. When boys with antisocial behavior problems and high levels of CU traits were simply told to attend to the eye region of emotional faces, their previously evident fear-recognition deficit disappeared (Dadds et al., 2006). It is likely that this specific fear-recognition deficit is a marker of a more profound deficit in the allocation of attention to socially relevant cues. Indeed, boys with high levels of CU traits and antisocial behavior problems have been shown to display less eye contact with their mothers than children with antisocial behavior problems without concurrent high levels of CU traits (Dadds et al., 2012). A lack of attention to socially relevant cues would, of course, impact on a child’s ability to form associations between his behavior and how it affects other people and would make it harder to learn when it was necessary to modify antisocial behaviors.
From Minor Deficits to Psychopathy
In all, the development of behaviors characteristic of those with high levels of CU traits may be simply a product of a lack of development, a lack of learning alternative behaviors, a lack of awareness early in childhood of the impact of their behavior on others. They may manifest a lack of understanding, perhaps, of a world in which they seem to function normally when they are, in fact, disabled by a cluster of subtle and complex cognitive deficits that over time snowball into robust and deleterious personality, and sometimes behavioral, traits.
These deficits, of course, do not exist in a vacuum but, rather, are constantly interacting with and influencing the social environment. For example, a child who makes less eye contact with his parent than a sibling does may be considered by the parent to be less engaging and less affectionate, leading to a deterioration in parental warmth—eroding the very dimension of parenting that is of most proximal importance to these children. In all, the development of psychopathy may be a real-life example of the childhood game of “telephone.” Cognitive differences may cause small, seemingly insignificant errors in the child’s understanding of behavior and social interaction that serve to mold his environment and compound his difficulties to result in behaviors and personality traits that, by the time adulthood is reached, may be so immoral as to appear unfathomable.
The lack of empathy that characterizes psychopathy and children with high levels of CU traits is one feature that has received considerable interest from both researchers and clinicians and points to complex interactions between cognitive and emotional deficits and the social environment. As with the aforementioned deficits in attention and learning, the difficulties with empathy demonstrated by children with high levels of CU traits are not straightforward. Empathy can be thought of as comprising two components: cognitive empathy and affective empathy. Cognitive empathy refers to the ability to understand how another person might feel in a given situation; for example, knowing someone might feel sad if her dog had just died or understanding that a classmate might feel angry if she were told off by the teacher for something she had not done. Affective empathy describes the sharing of an emotion with another person, for example, feeling like you want to cry when watching a sad film or feeling anxious for a friend who is about to take an examination and is displaying nervousness. Research has demonstrated that children with high levels of CU traits have no difficulties with cognitive empathy but display deficits in affective empathy (Jones, Happé, Gilbert, Burnett, & Viding, 2010). It is possible that this deficit is driven by a lack of awareness or of attention to the emotional states of others and may be reversed under conditions in which the child is directed to pay attention to the emotional cues of others such as facial expression, body posture, and tone of voice. Interestingly, fMRI research has found that these deficits in affective empathy are mirrored by neural function. Youths with psychopathic traits showed less amygdala activation than healthy youth in response to seeing images of pain inflicted on other people, but there were no differences in amygdala activation between the groups when the participant was asked to imagine that the pain was being inflicted on himself (Marsh et al., 2013). This finding suggests that the normal neurological underpinnings of the development of empathy may be altered or, at the very least, developmentally delayed in these adolescents. Research such as this helps us understand why a child with high levels of CU traits may be at a greater risk of developing, and maintaining, antisocial and aggressive behavior problems—such a child may be less sensitive to the impact, both emotional and physical, that his behavior has on others. In this regard empathy can be thought of as a stepping-stone in the pathway from basic neural and cognitive functions to the manifestation of complex personality and behavioral traits.
Concluding Remarks
The deficits in simple cognitive functions described in this chapter provide the basis of a pathway along which immoral behavior may develop. Basic functions such as learning and attention are the tools psychologists use to solve problems of behavior and to inform the development of treatments. This chapter presents a possible explanation for psychopathologies of immorality—for the development of callous-unemotional traits. Sociology, theology, and other disciplines concerned with immoral behavior have their own sets of tools to approach the problem and provide different possible explanations. Undoubtedly, both the combination of knowledge and the interactions among differing approaches allow for the best solutions. After all, a child does not develop in a void; his or her behavior is not solely a function of the subtle nuances of his or her cognitive processes. A child’s behavior is also influenced by that child’s physical environment, by his or her social environment, by that child’s beliefs and prior experiences, by his or her family dynamics, and by his or her successes and failures.
When we think of psychopathologies associated with immoral behavior, we tend to imagine the worst case scenarios. We tend to view criminal psychopaths as “monsters” who are somehow alien to the rest of the human race. By going to the extremes of immoral behaviors we make it difficult for ourselves to imagine the developmental course of such behaviors. When we take a step back, however, and consider basic psychological processes that lie at the root of these disorders, where these behaviors may have begun and how they may manifest in childhood, we can envisage a more innocent foundation on which improved interventions and treatments may be built.
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