Diagnosis & Treatment Planning
Key Points
Professional counselors benefit from utilizing clinical resources. When diagnosing, the DSM is the only reference to use on clinical documents (e.g. treatment plans).
“Psychopathy” is not a clinical diagnosis - but it is used interchangeably by many with the serious mental health disorder, Antisocial Personality Disorder (APD).
When in the role of mental health provider, it is advised to use diagnostic terms (e.g. APD) employed in treatment settings and official records (e.g. treatment plans).
APD cannot be diagnosed in children - but Conduct Disorder certainly can, and is a requirement for a future diagnosis of APD.
Ted Bundy, Jack the Ripper, and Jeffrey Dahmer were all psychopaths… and all were once 8 years old!
This article’s opening sentence is a bit hyperbolic and, perhaps, misleading (as is the title - but more on that in the next section). It is true that many would label these historic serial killers as “psychopaths”, but this term usually includes a wide spectrum of destructive behaviors (e.g. manipulating, rights violations) that do not include murder.
In addition, most children who display warning signs of psychopathy do not become adult psychopaths. That is the great news! The less inspiring news is that many child clients will display alarming behaviors that differ from their peers, and their counselors need to effectively treat them (and, oftentimes, their families). The process includes accurately diagnosing the client…
This article is designed to simplify the process of identifying childhood signs of what many will describe as “psychopathy”.
Psychopathy and Antisocial Personality Disorder
The label, “psychopath”, has become very confusing even for mental health professionals. One reason for the confusion is the continued, interchangeable use of psychopathy with the clinical diagnosis, Antisocial Personality Disorder (APD). This likely occurs due to the storied history of “psychopath”, which includes its use in previous DSM editions. Psychopathy was a diagnostic category in the first two DSM editions, but has since been replaced by APD (DeAngelis, 2022). Whatever the explanation, clinicians across the mental health fields struggle to fully understand how to use these clinical terms - and what they mean.
Let’s make it very easy for those of us working with children: We do not use “psychopath” or ASD when labeling children.
In fact, let’s take out the word, “psychopath”. When diagnosing or clinically describing behaviors, we use the latest edition of the DSM. “Psychopath” is not an option. Counselors have the option of ASD… but only for adult clients. One cannot diagnose anyone under age 18 with ASD!
If a clinician cannot diagnose a child with psychopathy, nor the diagnosis (i.e. ASD) that most actually mean when they use “psychopathy”... then this article’s title was very, very misleading! Rest assured, however, that the child and family counselor has a very real clinical guideline to consider in these cases: Conduct Disorder.
Conduct Disorder
As part of the diagnostic criteria for ASD, an individual must have had “evidence of conduct disorder with onset before age 15 years” (American Psychiatric Association, 2013, p.659). So, the clinical question is not if your child client is a psychopath, but if this individual is displaying signs of conduct disorder. This ailment can begin in preschool years, but meaningful symptoms usually manifest between the ages of 6-17. And as inferred above, most symptoms cease occurring in adulthood.
Symptoms
It is best to consult the latest edition of the DSM to diagnose a child with Conduct Disorder. Here is a preview: The many symptoms are organized under the following sections in the DSM 5 (American Psychiatric Association, 2013) diagnostic criteria for Conduct Disorder: “Aggression to People and Animals” (p.469) ,”Destruction of Property”, “Deceitfulness or Theft”, and “Serious Violations of Rules” (p.670).
Translation - When your child client is displaying the following symptoms, it is time to consider Conduct Disorder:
● harming other beings
● breaking things
● stealing or manipulating
● consistently breaking rules
To be clear: Our child clients cannot be diagnosed as a “psychopath” or even as having APD… our task is to see if the diagnostic criteria for Conduct Disorder best describes the client’s ailment.
Conclusion
In conclusion, psychopathy remains a very utilized clinical term among professionals and laypersons alike. Still, the mental health-related fields have struggled to define psychopathy, which is not a diagnosable condition in the DSM-V (DeAngelis, 2022). When speaking diagnostically and as professional counselors, we consider the DSM-V-TR condition, Antisocial Personality Disorder. Those of us working with children and adolescents will, when we have clients displaying alarming symptoms associated with harming others, need to consider Conduct Disorder as a diagnosis (as APD is not an option until one is 18 years old). At that point, the professional can research evidenced based treatment approaches to treat the client - and, perhaps, help facilitate healing from the disorder.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
DeAngelis, T. (2022). A broader view of psychopathy: New findings show that people with psychopathy have varying degrees and types of the condition. Monitor on Psychology, 53(2), 46-51.
Dr. John Grady, PhD, is a dual licensed clinical counselor (LPC, LCADC) and dual certified clinical supervisor (ACS, CCS) with a doctorate in organizational leadership. Dr. Grady teaches in the Applied Psychology department at New York University, and has taught Human Services at Purdue University and Counselor Education at Kean University. Dr. Grady can be contacted for questions, comments, etc. at his LinkedIn account.
Important: This article should not be used in the diagnostic process of any client. To construct an educated accurate diagnosis, use the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Then, when constructing your treatment plan, consider the use of evidenced based interventions for that diagnosis (or diagnoses). Always consult with supervisors, mentors, or peers in the counseling-related fields should you have questions regarding your work as a counseling professional.
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