To curb violent tendencies, start young Working with aggressive children prevents some from becoming violent, criminal adults

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DURHAM, N.C. -- Aggressive children are less likely to become violent criminals or psychiatrically troubled adults if they receive early intervention, says a new study based on more than two decades of research. "These findings from researchers at Duke, Pennsylvania State and Vanderbilt universities and the University of Washington are based on the Fast Track Project, a multi-faceted program that is one of the largest violence-prevention trials ever funded by the federal government. Beginning in 1991, the researchers screened nearly 10,000 5-year-old children in Durham, Nashville, Seattle and rural Pennsylvania for aggressive behavior problems, identifying those who were at highest risk of growing up to become violent, antisocial adults. Nearly 900 children were deemed at high risk, and of those, half were randomly assigned to receive the Fast Track intervention, while the other half were assigned to a control group. Participating children and their families received an array of interventions at school and at home. Nineteen years later, the authors found that Fast Track participants at age 25 had fewer convictions for violent and drug-related crimes, lower rates of serious substance abuse, lower rates of risky sexual behavior and fewer psychiatric problems than the control group. "We can prevent serious violence and psychopathology among the group of children who are highest-risk," said Duke's Kenneth Dodge. "That's the essential finding from this study. It provides the strongest evidence yet that, far from being doomed from an early age, at-risk children can be helped to live productive lives." Dodge directs the Duke Center for Child and Family Policy and is the William McDougall Professor of Public Policy at Duke's Sanford School of Public Policy. The program's positive effects held true across four different sites around the country, among both males and females and among both white and African-American children. The study appears online Sept. 15 in the American Journal of Psychiatry. From first through 10th grade, the Fast Track children received reading tutoring and specialized intervention aimed at improving self-control and social-cognitive skills. Parents learned problem-solving skills through home visits and parent training groups. When program participants turned 25, researchers reviewed court records and conducted interviews with participants and control group members, as well as individuals who knew the participants well. Along with fewer criminal convictions, Fast Track participants had lower rates of antisocial personality disorder and avoidant personality disorder, lower rates of risky sexual behavior and lower rates of harsh parenting. The latter finding suggests that the intervention may interrupt the inter-generational cycle of problem behavior. Fast Track is among very few studies to test the long-term effect of environment on children's development through a clinical trial. It provides strong evidence for the critical role environment plays in shaping a child's development. "This study adds to the experimental evidence for the important role that environment plays," Dodge said. "Genes do not write an inalterable script for a child's life. And not only does the environment matter greatly in a child's development, we've shown that you can intervene and help that child succeed in life." Fast Track's positive effects do not come cheap. The 10-year intervention costs $58,000 per child. However, that cost should be weighed against the millions of dollars that each chronic criminal costs society in imprisonment and harm to others, Dodge said. "Prevention takes a considerable investment, but that investment is worth it," Dodge said. "Our policies and practices should reflect the fact that these children can have productive lives." In future studies, Dodge and his colleagues plan to examine the cost-benefit question more closely. ### The research was supported by grants from the National Institute of Mental Health (NIMH R18 MH48043, R18 MH50951, R18 MH50952, R18 MH50953, K05MH00797 and K05MH01027), the Department of Education (grant S184U30002) and the National Institute on Drug Abuse (NIDA grants DA16903, DA017589, K05DA015226, and P30DA023026). The Center for Substance Abuse Prevention and the National Institute on Drug Abuse also provided support through a memorandum of agreement with the NIMH. Financial disclosure: Study authors Kenneth Dodge, Karen Bierman, John Coie, Mark Greenberg, John Lochman and Robert McMahon are the developers of the Fast Track curriculum and have a publishing agreement with Guilford Press. Greenberg is also an author of the PATHS curriculum, which is used in the Fast Track program. McMahon is a co-author of Helping the Noncompliant Child and has a royalty agreement with Guilford Publications. He is also a member of the Treatments that Work Scientific Advisory Board with Oxford University Press. The other authors have no financial relationships to disclose." CITATION: "Impact of Early Intervention on Psychopathology, Crime and Well-Being at Age 25," Kenneth A. Dodge and the Conduct Problems Prevention Research Group. American Journal of Psychiatry, September 15, 2014. DOI: 10.1176/appi.ajp.2014.13060786. For more information on mental health topis, please visit CEUs for Counselors

Bad boys: Research predicts whether boys will grow out of it -- or not

ANN ARBOR --- Using the hi-tech tools of a new field called neurogenetics and a few simple questions for parents, a University of Michigan researcher is beginning to understand which boys are simply being boys and which may be headed for trouble. “When young children lie or cheat or steal, parents naturally wonder if they’ll grow out of it,” says Luke Hyde, a U-M psychologist who is studying the development and treatment of antisocial behavior. Hyde, a faculty associate at the U-M Institute for Social Research (ISR) and assistant professor of psychology, is speaking at ISR on November 11 on how genes, experience and the brain work together to heighten or reduce the risks that normal childhood transgressions will develop into full-blown conduct disorders in adolescence and early adulthood. His talk is part of the ISR Research Center for Group Dynamics seminar series on violence and aggression, and is free and open to the public. “The lifetime prevalence of conduct disorder is around 10 percent, and even higher in males and low-income populations,” says Hyde. “The total cost to society is enormous, since these behaviors are often chronic, lasting through adulthood.” MHC Continuing Education With colleagues at U-M, Duke University, the University of Pittsburgh, and other institutions, Hyde has been exploring the role of the environment and biology as they interact over time to shape behavior. In particular, he is using the techniques of a new field called neurogenetics, which combines genetics, neuroscience and psychology, to learn how genes and neural processes interact with harsh environments, including dangerous neighborhoods and harsh parents, and with a child’s own levels of empathy and personality traits, to increase the risk of antisocial behavior. In one recent study, for example, Hyde and colleagues studied subjects with over-reactive amygdala responses . The amygdala is an almond-shaped part of the brain’s primitive limbic system involved in processing fear and other visceral emotions. It has been associated with impulsive, aggressive behavior, as well as anxiety disorders and depression. “Previous research suggests that the amygdala becomes over-reactive probably as a result of both genetics and experience,” says Hyde. “And once the amygdala is over-reactive, people tend to behave in an anxious, over-reactive way to things they see as a potential threat. “Our study found that this tendency is moderated by a person’s environment, including the social support they get. If they’re not getting support from family, friends, neighbors, or professionals, then the link between the amygdala and anxious behavior is much stronger.” In another study, Hyde and colleagues showed that kids who are impulsive are only at higher risk of engaging in antisocial behavior if they live in dangerous neighborhoods. He also identified specific items within childhood behavior checklists that can be used as early as the age of three to identify kids who will likely have worse trajectories for anti-social behavior compared to other children who have similar behavior problems, such as throwing tantrums. These items assess observable behaviors that include whether the child is cruel to animals, doesn’t seem to feel guilty after misbehaving, is sneaky, lies, is selfish or won’t share, and won’t change his or her behavior as a result of punishment. “The results of this test aren’t really meaningful until age three or three-and-a-half,” says Hyde. “Before that, many of these behaviors are fairly common, and don’t predict anything. But after age three, if children are still behaving in these ways, their behavior is more likely to escalate in the following years rather than improve.” There is good news, though. Kids who scored high on this test benefitted just as much as other kids from interventions, according to Hyde. These interventions, often called parent management training, focus on giving parents better skills to manage child behavior problems, including training parents to spend more positive time with their kids, use time-outs instead of physical punishments, and reward good behavior by giving out stickers. “Parents need to know that intervention works, especially if it’s done early,” says Hyde. “They need to go for help if they see signs of trouble. Clinical psychologists, among other professionals, have empirically supported treatments that are quite effective for children, especially in this age period.” ### Funding for this research was provided by The National Institute of Drug Abuse, the National Institute of Mental Health, and the National Heart, Lung and Blood Institute. Established in 1949, the University of Michigan Institute for Social Research (ISR) is the world's largest academic social science survey and research organization, and a world leader in developing and applying social science methodology, and educating researchers and students from around the world. For more information, visit the ISR Web site at http://home.isr.umich.edu

Mentally Ill Often Targets of Violence

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Simple tool may help inexperienced psychiatrists better predict violence risk in patients, U-M study finds

Without assessment tool, inexperienced psychiatrists less likely to accurately predict violence ANN ARBOR, Mich. Inexperienced psychiatrists are less likely than their veteran peers to accurately predict violence by their patients, but a simple assessment checklist might help bridge that accuracy gap, according to new research from the University of Michigan. Led by psychiatrist Alan Teo, M.D., a Robert Wood Johnson Foundation Clinical Scholar of the University of Michigan, researchers examined how accurate psychiatrists were at predicting assaults by acutely ill patients admitted to psychiatric units. Their results found that inexperienced psychiatric resident doctors did no better than a coin flip, whereas veteran psychiatrists were 70 percent accurate in predicting risk of violence. However, when a brief risk assessment tool was applied to the cases that the junior doctors evaluated, their level of accuracy jumped to 67 percent, or nearly as good as the more experienced psychiatrists. Results of the research were published online Sept. 1 in the journal Psychiatric Services. “The tool we used, called the HCR-20-C, is remarkably brief and straightforward. Like a checklist a pilot might use before takeoff, it has just five items that any trained mental health professional can assess,” Teo says. In light of recent violent events, such as the movie theater shooting in Aurora, Colo,, earlier this summer, Teo says predicting violence risk in psychiatric patients is an increasingly important topic. “Given public concern about this issue, I think teaching our budding psychiatrists and others how to use a practical tool like this, and encouraging its use in high-risk settings is a no-brainer,” he says. In the study, researchers were able to assess doctors’ accuracy by comparing patients who had assaulted hospital staff members with similar patients who had not been violent. Because all patients received a threat assessment when admitted to the psychiatric unit, the researchers were able to compare a patient’s predicted violence risk with whether they actually had a documented assault while in the hospital. Incidents of physical aggression typically included punching, slapping, or throwing objects, as well as yelling, directed at staff members of the hospital. The patients studied had severe illnesses, often schizophrenia, and had been involuntarily admitted to the hospital. Teo says this study is the first to compare the predictive success of violence assessment between experienced and inexperienced psychiatrists. The results, he says, highlight the importance of emphasizing violence risk assessment in clinical training programs ceus for counselors “If trainees are indeed less able than trained and experienced clinicians to accurately perform risk assessments for violence, it’s important to figure out a way to improve their accuracy,” he says. “Our study shows that evidence-based structured tools might have the potential to augment training and improve risk assessment.” ### Citation: Psychiatric Services, Sept. 1, 2012; doi: 10.1176/appi.ps.201200019 Other authors: Sarah R. Holley, Ph.D.; Mary Leary, M.D.; Dale E. McNiel, Ph.D. Conflicts of interest: None. Funding: This work was partly supported by the National Institute of Mental Health (grant R25 MH060482), a Minority Fellowship sponsored by the American Psychiatric Association and the Substance Abuse and Mental Health Services Administration, and a Clinical and Translational Science Award (ULI RR024131) from the National Institutes of Health.

Exposure to violence has long-term stress effects among adolescents

UNIVERSITY PARK, Pa. -- Children who are exposed to community violence continue to exhibit a physical stress response up to a year after the exposure, suggesting that exposure to violence may have long-term negative health consequences, according researchers at Penn State and University College London. "We know that exposure to violence is linked with aggression, depression, post-traumatic stress symptoms and academic and cognitive difficulties in the short term, but little is known about the long-term effects of such exposure," said Elizabeth Susman, Jean Phillips Shibley Professor of Biobehavioral Health, Penn State. "Our data show that the stress reaction to violence exposure is not just immediate. There's an effect that endures." The scientists recruited 124 adolescents, ranging in age from 8 to 13 and living in small city and rural communities, to participate in the study social worker continuing education "Most studies of the effects of exposure to violence look at children who live in inner cities and urban communities," said Melissa Peckins, biobehavioral health graduate student, Penn State. "Our study is unique because we focused on children who live in small towns, so they are not children you would normally expect to be exposed to a lot of violence. Also, these were healthy children without a history of reported maltreatment." The researchers gave each of the adolescents a questionnaire, which identified their lifetime exposure to violence and exposure within the past 12 months. They then gave the adolescents the beginning of a story and asked them to complete it in front of two mock judges, whom they were told were evaluating their responses and performances for later comparison to those of other children the same age. Following the story-completion task, adolescents were also given a serial subtraction task. "The story completion task and mental arithmetic task are commonly used to elicit a stress response in laboratory settings," Peckins said. "Our hypothesis was that children who have been exposed to more violent events in the past year will have an attenuated response to the laboratory stressor -- even 12 months after the incidence -- compared with children who experienced fewer violent events." The team measured the children's stress responses by comparing the cortisol levels present in samples of their saliva collected before and after the stress test was administered. "In males, we found that as exposure to violence increased, cortisol reactivity decreased, so cortisol reactivity was attenuated; it was a habituation effect," Peckins said. The finding was not present in females. The results were published online in a recent issue of the Journal of Adolescent Health. "In enduring stressful conditions, we may have adapted evolutionarily to suppress our cortisol levels because higher and more prolonged levels of cortisol in the bloodstream can lead to negative health consequences, such as autoimmune disorders, lowered immunity, arthritis and atypical depression. This may explain why cortisol reactivity was lower for males," Susman said. "However, there is a theory that females may react to stressful situations by talking about it, which may be their way of reducing the negative effects of cortisol in the bloodstream. If parents and other adults are available to discuss episodes of violence with children, it might help the children, especially females, to reduce their cortisol levels." In the future, the team hopes to examine the role of duration of exposure to violence and time elapsed after exposure to violence on cortisol reactivity. ### Other researchers on this project were Samantha Dockray, research fellow, University College London, and Jacey Eckenrode, graduate student in biobehavioral health and Jodi Heaton, administrative assistant, biobehavioral health, both at Penn State. The National Institute of Mental Health, the General Clinical Research Center of the National Institutes of Health and Penn State supported this work.

Study identifies factors related to violence in veterans

CHAPEL HILL, N.C. – A national survey identifies which U.S. military veterans may be at most risk of aggression after deployment and what strategies could potentially help reduce likelihood of violence when service members return home counselor ceus The study examined protective factors that are important in preventing violence, including employment, meeting basic needs, living stability, social support, spiritual faith, ability to care for oneself, perceived self-determination, and resilience (ability to adapt to stress). Veterans with these factors in place were 92 percent less likely to report severe violence than veterans who did not endorse these factors. The majority of veterans (over three-quarters of those studied) did endorse most of these protective factors and thus posed a low threat of violence. These findings are reported in an article published June 25, 2012 in the Journal of Clinical Psychiatry of a National Institute of Mental Health-funded study led by Eric B. Elbogen, PhD, Research Director of the Forensic Psychiatry Program in the University of North Carolina School of Medicine and Psychologist in the U.S. Department of Veterans Affairs. "When you hear about veterans committing acts of violence, many people assume that post-traumatic stress disorder (PTSD) or combat exposure are to blame," Elbogen said. "But our study shows that is not necessarily true." The national survey revealed that other factors are just as important to understanding violence in veterans, including alcohol misuse, criminal background, as well as veterans' living, work, social, and financial circumstances. In fact, the survey found that veterans who didn't have enough money to cover basic needs were more likely to report aggressive behavior than veterans with PTSD. "Our study suggests the incidence of violence could be reduced by helping veterans develop and maintain protective factors in their lives back home," Elbogen said. The survey was conducted between July 2009 and April 2010. Responses were collected from 1,388 veterans who served in the Iraq and Afghanistan War era and theater after Sept. 11, 2001. The sample included veterans from all branches of the U.S. military and all 50 states. One-third of survey respondents self-identified committing an act of aggression towards others in the past year, most of which involved relatively minor aggressive behavior. Eleven percent of the sample reported more severe violence. Elbogen noted, "Although the majority of study participants did not report aggression, the potential for violence does remain a significant concern among a subset of returning veterans." Dr. Sally Johnson, co-author and Professor in the UNC Forensic Psychiatry Program, points out "Some veterans do not cope well with the loss of the structure, social, and financial support available in the military environment. Attention to helping veterans establish psychosocial stability in the civilian environment can help reduce post-deployment adjustment problems including aggression." ### The other co-authors H. Ryan Wagner, PhD, Virginia M. Newton, PhD Christine Timko, PhD, Jennifer J. Vasterling, PhD, and Jean C. Beckham, PhD are affiliated with the Department of Veterans Affairs.

In a nationally representative survey of 12- to 17-year-old youth and their trauma experiences, 39 percent reported witnessing violence, 17 percent reported physical assault, and 8 percent reported a lifetime prevalence of sexual assault.

April 2012 Social Media Message

In a nationally representative survey of 12- to 17-year-old youth and their trauma experiences, 39 percent reported witnessing violence, 17 percent reported physical assault, and 8 percent reported a lifetime prevalence of sexual assault. With help from families, friends, providers, and other Heroes of Hope, children and youth can be resilient when dealing with trauma. Visit www.samhsa.gov/children to learn more. When looking at rates of exposure to traumatic events, a nationally representative survey reported that among 12- to 17-year-old youth, 39 percent reported witnessing violence, 17 percent reported physical assault, and 8 percent reported a lifetime prevalence of sexual assault.1, 2 ceus for social workers Research has shown that caregivers can buffer the impact of trauma and promote better outcomes for children, even under stressful times, when the following Strengthening Families Protective Factors are present: •Parental resilience •Social connections •Knowledge of parenting and child development •Concrete support in times of need •Social and emotional competence of children3 Use these sample messages to share this childhood trauma and resilience data point with your connections on Twitter and Facebook and via email. Twitter: 39% of 12- to 17-year-old youths have reported witnessing violence, learn more: http://1.usa.gov/Ie4UjT via @samhsagov #HeroesofHope Facebook: A national survey of 12- to 17-year-old youths found that 17 percent reported physical assault and 8 percent reported a lifetime prevalence of sexual assault. Learn more about the behavioral health impact of traumatic events on children and youth and pass it on to observe National Children's Mental Health Awareness Day: http://1.usa.gov/Ie4UjT

References: 1. Kilpatrick DG, Acierno R. (2003). Mental health needs of crime victims: Epidemiology and outcomes. Journal of Traumatic Stress.16(2),119–132. Retrieved from http://onlinelibrary.wiley.com/doi/10.1023/A:1022891005388/abstract . 2.Saunders BE. (2003). Understanding Children Exposed to Violence Toward an Integration of Overlapping Fields. National Crime Victims Research and Treatment Center. J Interpers Violence. 18(4) 356-376. Retrieved from http://jiv.sagepub.com/content/18/4/356.short . 3.Horton, C. (2003). Protective factors literature review. Early care and education programs and the prevention of child abuse and neglect. Center for the Study of Social Policy.