Background
While many behavioral and psychiatric disorders have a biological base, they may also have roots in early childhood maltreatment and in exposure to violence. The overlap between behavioral /psychiatric disorders and histories of childhood trauma is greater than has been previously recognized. In order to examine this, the relationships among behavior problems, sexual offending, substance abuse, impulsivity, psychiatric symptoms, attachment disorders, youth violence, abuse and neglect histories, and family violence were studied among a sample of 246 youth.

In this study, most children and teens with histories of abuse, neglect, and family violence also had problems with hyperactivity, impulsivity, distractibility, mood problems, anxiety, enuresis, behavior problems, sexual offending, paranoia, and assaultive behaviors. These youth were often diagnosed with ADHD, Oppositional Defiant Disorder, Conduct Disorder, or a mood disorder. The majority of youth with Attachment Disorders, aggression, substance abuse, sexual offending, and psychiatric problems in this sample had histories of family violence and impulsivity, as well. PTSD and attachment problems are often not examined as part of the diagnostic picture of these youth. Assessment and treatment for behavioral, sexual, and psychiatric disorders among young people should include assessment and treatment of all client needs as well as those of the family. Youth and families with multiple problems and the involvement of multiple agencies need coordination of care and a wrap around or multi-systems approach to the overall intervention.

The high level of co-occurrence of ADHD and conduct disorder is well documented. It is hypothesized that many children with this particular co-occurrence may be attachment disordered, as well. Attachment Disordered youth have been severely neglected, abused, or exposed to domestic violence, resulting in behaviors that are often violent, oppositional, and antisocial. However, the co-occurrence of family violence and child maltreatment with these disorders has not been established in previous studies. Problems associated with trauma and attachment may be the root of many hyperactivity and behavioral problems. Reid Meloy makes a case for the relationship between attachment disorder in childhood and psychopathy in adulthood in his book, “The Mark of Cain.”

Sample
The present sample has 550 participants. All youth were administered the CARE. The sample includes clients in east coast and mid-western US residential and outpatient treatment settings, as well as a detention center and a youth prison.
Method

The CARE is a tool that assesses the risk of youth violence. It contains items on youth and family history, behavior, mental health problems, school behavior, peer issues, and skill areas. Data was collected through a combination of interview and record review. Names were not placed on the CARE forms so that youth confidentiality was maintained. Data was subjected to statistical analysis.

Theory
Parents with high conflict and low warmth often have mental health, addictions, and behavioral problems. When they do, they have difficulty with appropriate, nurturing, and consistent care of their children. When the parents solve their problems by using aggression and violence, the children learn that behavior as a coping strategy. When caregivers are depressed, addicted, attachment disordered, or have poor coping skills, the children may have difficulty bonding to their parents. Caregiver bonding is necessary for future bonding to school, community and peers. Pathological caregiving results in problems with brain development, also. This results in poor problem solving and difficulty with logic. It may result in learning problems, as well. Social relatedness and moral development are also impaired.

Many aggressive youth are enuretic, even as teenagers. Some children with severe behavior problems are as young as 3 years old. Attachment Disordered youth, by definition have experienced pathological caregiving, such as severe neglect, abuse or exposure to domestic violence. It is hypothesized that the diagnoses, Oppositional-Defiant Disorder, Conduct Disorder, and ADHD may be over used, while PTSD and Attachment Disorder may be underused. The importance of the distinctions among these disorders is two-fold. Conduct and Oppositional Defiant Disorders are seen by many as the volitional behaviors of “bad” kids. These youth already have a poor self-image. The negative connotation about the diagnoses further supports negative thinking about these adolescents. Secondly, the treatment used for these youth is often behavior modification or cognitive behavioral treatment. Many of these youth are attachment disordered. Cognitive-behavioral methods have been shown to be useful, but insufficient for the treatment of youth with attachment disorders.

Results
To assess the pervasiveness of family violence and abuse and neglect issues among youth with aggression and behavior problems, the risk and resiliency items of the CARE were placed in a regression equation. CARE risk and resiliency factors were analyzed and the strongest statistical predictors of violent offending were identified. These included enuresis, behavior problems before the age of 12, running away from home, odd, psychotic, schizoid, or self-harming behavior, and attachment disorder.

A model of the development of violent offending was developed. The model shows that low family warmth and high conflict is associated with family violence. Family violence is related to the abuse and neglect of children. When the abuse or neglect occurs in the preschool years, it is associated with attachment disorders or problems. Attachment problems are then exhibited by enuresis, impulsivity, lack of empathy, early behavior problems, paranoia, and aggression. When family violence or neglect occurs later in childhood, it results in conduct problems that are probably learned behaviors coupled with poor problem solving, social skills, self-soothing, and anger management. The symptoms are similar: behavior problems, aggression, impulsivity, and paranoia. When the path is PTSD, the symptoms are probably more defensive in nature, but the results are, again, similar: impulsivity, behavior problems, aggression, and paranoia. However, children do not neatly take one path or the other. Their behaviors are more likely the result of a combination of factors.

Implications for Practice

The implications for intervention are that regardless of the reason that a person comes to the attention of a criminal justice, social service, or mental health agency, there is a high likelihood that other problems exist within the individual and the family. All problem areas should be assessed and either treated or referred for treatment. This study also makes a case for providing early mental health services for the children who have been abused, neglected, or exposed to domestic violence. To end youth and adult violence, we must look at the violent family roots and intervene as early as possible.

Conclusions
Groups of people with Psychiatric Disorders, Substance Abuse Problems, Sexual Offending, and Violent Offending had a high percentage of youth or adults who had experienced childhood trauma or were from families with histories of violence (See Figures 1, 2, and 3). All groups had a high level of those with psychiatric problems. The majority of substance abusers, sexual offenders and those with Attachment Disorders were also physically assaultive. A large percentage of Substance Abusers and sexual offenders also had histories of other criminal or delinquent activities. Specifically, eighty-three percent of the violent youth or adults had an attachment disorder and ninety-two percent of the Attachment Disordered youth or adults had psychiatric problems.

Violent offenders had attachment disorders, severe behavior problems, enuresis, impulsivity, anger problems, poor social skills, and school behavior problems. Those with Attachment Disorders had experienced childhood trauma and had demonstrated emotional displays that were flat or out of control, severe behavior problems, and physical assaultiveness. Substance abusers had severe behavior problems and were delinquent or criminal. The psychiatric group had psychosis, parental discipline that was lax, inconsistent, or harsh, childhood trauma and family violence. The sexual offenders were primarily male and had low IQ, physical assaults, deviant peers, severe behavior problems, and other delinquencies.

The treatment of co-morbid conditions needs further study. Effective assessments and interventions for attachment disorders need to be developed. Agencies should be using multimodal assessments and interventions that address the needs of the client and the entire family group.

Author's Bio: 

Kathryn Seifert received her Ph.D. from the University of Maryland, Baltimore Campus in 1995. She advocates for the highest quality services for all children needing mental health treatment.

Dr. Seifert has had over 30 years experience in mental health, addictions, and criminal justice work. In addition to creating the Juvenile CARE2 (Chronic Violent Behavior Risk and Needs Assessment), Dr. Seifert has authored articles and lectured nationally and internationally on family violence and trauma. She founded Eastern Shore Psychological Services, a multidisciplinary private practice that specializes in working with high-risk youth and their families. She lectures nationally and internationally on the topics of violence, risk assessment, suicide prevention, and stress management.

Her latest book is “How Children Become Violent: Keeping Your Kids Out of Gangs, Terrorist Organizations, and Cults.” In her book, she describes her theory of risk and resiliency factors interacting with childhood development, which ultimately lead to appropriate or inappropriate interpersonal behaviors. She outlines assessment, prevention and assessment strategies to prevent future violence. You may visit her website at http://drkathyseifert.com.

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