“No behavioral abnormalities were observed until the age of three years, when she was first noted to be largely unresponsive to verbal or physical punishment. Her behavior became progressively disruptive, so much so that, by age 14, she required placement in the first of several treatment facilities. Her teachers considered her to be intelligent and academically capable, but she routinely failed to complete assigned tasks. Her adolescence was marked by disruptive behavior in school and at home (for example, failure to comply with rules, frequent loud confrontations with peers and adults). She stole from her family and from other children and shoplifted frequently, leading to multiple arrests. She was verbally and physically abusive to others. She lied chronically. Her lack of friends was conspicuous. She ran away from home and from treatment facilities. She exhibited early and risky sexual behavior leading to a pregnancy at age 18. Contingency management in residential treatment facilities and the use of psychotropic medication were of no help. After repeatedly putting herself at physical and financial risk, she became entirely dependent on her parents and on social agencies for financial support and oversight of her personal affairs. She did not formulate any plans for her future and she sought no employment. Whenever employment was arranged, she was unable to hold the job due to lack of dependability and gross infractions of rules. Affect was labile and often poorly matched to the situation, but superficial social behavior was unremarkable. She never expressed guilt or remorse for her misbehavior. There was little or no evidence that she experienced empathy, and her maternal behavior was marked by dangerous insensitivity to the infant’s needs. She blamed her misdeeds and social difficulties on other people, and she denied any difficulties with cognition or behavior.”
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