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Weekly UpdatesWhen a child lies, shoplifts, or seems to show little remorse after a thoughtless act, families may raise the question, is this a single event or the first sign of a serious lifelong character flaw?
They may have considered with dread that their teen's inflated self-image and self-centeredness are indicative of narcissism, a lifelong pattern of self-centered thinking.
They wonder, is today's flippant school vandal tomorrow's gang member and adult psychopathic criminal?
Will the loner who has trouble relating to family or peers become a shut-in or live a life of loneliness in adulthood?
Although they may not know the labels, what these families are asking is whether troubled youths are destined to be locked in personality patterns that will define their lives--one of the personality disorders categorized in the DSM-IV in clusters (paranoid, schizoid, schizotypal; antisocial, borderline, histrionic, narcissistic; avoidant, dependent, or obsessive compulsive).
In contrast to a behavior, a phase, or a trait, a disorder of personality is generally believed to be quite fixed in adulthood, framing relationships and experiences according to rigid defenses and distorted expectations of others.
While most adults have a healthy mixture of personality traits, we can all point to adults we've encountered in our lives who demonstrate strikingly consistent, rigid patterns of thinking and interacting. They may see others through a prism of superiority or inferiority, distrust or disregard. They may feel themselves constantly victimized, or perhaps they live lives of unrelenting drama or brittle isolation.
Most feared are psychopaths we read about who seemingly take pleasure in harming others for their own gain, not as a result of obvious psychosis, but seemingly as a reflection of a personality devoid of empathy or conscience.
What is most important to convey to parents is the message that adult personality disorders are very slow to develop and are profoundly difficult to predict in a child or adolescent; they are rarely diagnosed in a child under 18 and then, only when they have been present for a year or more. Antisocial personality disorder, by definition, cannot be diagnosed in a child under 18. The American Psychiatric Association defines a personality disorder as "an enduring pattern of inner experience and behavior that deviates markedly from the culture of the individual who exhibits it."
Unlike temperamental traits, which are evident from infancy and very relevant in early childhood but change over time, personality is a gradually evolving portrait of identity influenced by genetics, interpersonal style, relationships, culture, and life events.
The slow-to-warm-up kindergartener who clings to parents in September may be exhibiting a transient behavior that will disappear by Thanksgiving. He or she may prove to have a more lasting temperamental tendency toward shyness, but this is normal and expected, not indicative of a more serious personality disorder.
The child who tells a lie in grade school may have many motivations: wanting to protect a friend, to avoid punishment, or to cover up a poor grade and avoid an angry parent. Teenagers may lie because they want to maintain an image, protect their privacy, or buy time while they figure a way out of a bind.
None of these lies necessarily predicts delinquency, much less criminality in adulthood or a deeply entrenched, enduring pattern of deceiving others with no remorse.
Although children with worrisome traits do deserve attention and support, they do not deserve labels or an over-investment in predicting a child's future.
Certainly, it may be helpful to discuss with parents of a very quiet, private child whether their own childhoods were similar and whether it caused them discomfort later in life. If the child is amenable, a gentle encouragement of more social, rambunctious activities--karate, soccer, or joining a band, for example--might be in order.
Likewise, the roots of a lying child's deceptions should be explored and attempts made to foster trust, responsibility, and truthfulness during a period of time when it is clear that traits can be softened, if not altered.
Parents deserve a special word of caution about overinterpreting behaviors or traits in adolescence. Youths commonly "'try on" identities in a fluid manner, appearing narcissistic, then masochistic and recover by looking avoidant--reacting to parents with histrionic resistance 1 minute and hints of dependent insecurity the next. In the words of Anna Freud: "'Such fluctuations between extreme opposites would be deemed highly abnormal at any other time of life. At this time, they may actually signify no more than that an adult structure of personality takes a long time to emerge."
What's missing from this fluid portrait of adolescent identity, if one were to start tracing the origins of a personality disorder, is rigidity and consistency forming a pattern over the years. We suspect that genetics interacting with cognitive style and life experiences can all be mutually reinforcing and result in a personality disorder. A child with attention-deficit/hyperactivity disorder who has learning disorders and a pattern of being physically aggressive can have that behavior reinforced by abuse at home and constant frustration by a daunting school curriculum. A lack of services and opportunities to join a gang all support movement to delinquency.
The precursors will not be easily missed or confused with the occasional behavioral indiscretion or a phase of social withdrawal. Instead, you may notice long-standing patterns of rigid, inflexible responses to the child's environment, beginning with relationships. In general, people with personality disorders have difficulty relating to others because they cannot easily distinguish a person's actual behavior or motivations from what they need that person to be in their tightly defended, protective script of how life goes.
What may at first look like cold insensitivity is really part of a self-fulfilling belief that others cannot be depended on to fulfill one's needs.
Efforts to offer a different perspective through new experiences--encouraging social activity by the withdrawn child or pro-social volunteering by the cruel bully-are often found to be frustratingly unsuccessful as such a child closes the protective curtains around his or her strongly fortified defenses.
Another important sign of enduring personality entrenchment is the degree of intensity of such traits.
We all know that many children roughhouse on the elementary school playground, but it is highly unusual to see serious injuries inflicted intentionally by one child on another in the course of a schoolyard fight. If a child is repeatedly at the center of violent interactions, either as perpetrator or victim, and seems impervious to interventions made by numerous adults, a theory might be that a personality disorder is developing that may require intensive evaluation and treatment.
Such a child requires a sensitive multi-factorial assessment of his or her vulnerability as well as the surrounding environment and a thoughtful referral to a psychiatrist or psychologist before longstanding beliefs become a personality disorder that may frame the child's worldview for life. Trying to soften or modify an emerging personality disorder requires a comprehensive approach over time.
DR. JELLINEK is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, both in Boston. To respond to this column, e-mail Dr. Jellinek at pdnews@elsevier.com.
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