- Email: [email protected]
Early Identification and Treatment of Antisocial Behavior
Early Identification and Tre a t m e n t o f A n t i s o c i a l Behavior Paul J. Frick,
PhD
a,b,
*
KEYWORDS Antisocial behavior Early identification Treatment Callous-unemotional traits Emotional regulation Diagnosis KEY POINTS Individuals most likely to show severe and persistent antisocial behavior often begin showing severe conduct problems early in childhood. Callous-unemotional (CU) traits are characterized by a lack of guilt, a lack of empathy, a restricted display of affect, and a failure to put forth the effort to succeed in important activities. The level of CU traits seems to differentiate subgroups of children and adolescents with serious conduct problems who differ in the severity and persistence of their antisocial behavior. The level of CU traits also seems to differentiate subgroups of children and adolescents with serious conduct who have different causes to their behavior problems. Treatment is enhanced when it is tailored to the unique characteristics of antisocial youth with and without elevated CU traits.
INTRODUCTION
Antisocial behavior in children and adolescents is generally defined by behavior that violates the rights of others, such as aggression, destruction of property, and theft; or behavior that violates major age-appropriate societal norms or rules, such as truancy and running away from home.1 Serious and persistent patterns of antisocial behavior in children and adolescents form the diagnostic criteria for conduct disorder (CD),1 and CD is a critical mental health concern for several reasons: It is highly prevalent with a worldwide prevalence among children and adolescents ages 6 to 18 estimated at 3.2%.2
Disclosure Statement: The author has nothing to disclose. a Department of Psychology, Louisiana State University, Baton Rouge, LA 70802, USA; b Learning Sciences Institute of Australia, Australian Catholic University, Melbourne, VIC, Australia * Department of Psychology, Louisiana State University, Baton Rouge, LA 70802. E-mail address: [email protected] Pediatr Clin N Am 63 (2016) 861–871 http://dx.doi.org/10.1016/j.pcl.2016.06.008 pediatric.theclinics.com 0031-3955/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
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It operates at a high cost to society because of the reduced quality of life for the victims of the antisocial acts and the financial costs to the legal system that must respond to the acts that violate laws.3 It predicts a host of problems in adjustment for the person with the disorder throughout their lifespan, including mental health problems (eg, substance abuse), legal problems (eg, risk for arrest), educational problems (eg, school dropout), social problems (eg, poor marital adjustment), occupational problems (eg, poor job performance), and physical health problems (eg, poor respiratory function).4 Given the prevalence, cost, and impairment associated with CD, it is not surprising that a substantial amount of research has been conducted to understand the causes of this disorder and to use this knowledge to develop effective methods to prevent or treat it. One of the most consistent findings from this work is that interventions that seek to target a reduction in antisocial behavior are least costly and most effective if they are implemented early in childhood.5 As a result, a substantial amount of research on CD has focused on identifying early markers that predict either who will develop the disorder or who is at risk for showing the most severe and persistent forms of antisocial behavior once it develops. BEHAVIORAL APPROACHES TO EARLY IDENTIFICATION Types of Behavior Associated with Poor Outcomes
Early research attempting to identify early indicators of risk for persistent antisocial behavior focused on the frequency and severity of the behavior displayed, with severity being defined as the number and variety of different behaviors displayed by the child and the number of settings in which the child displays the behaviors.6 For example, Robins reported on a classic longitudinal study of 314 children referred to a child mental health clinic for CD symptoms and reported that the risk for showing an antisocial disorder as an adult was a linear function of the number of symptoms exhibited in childhood.7 Specifically, 15% of children with 3 to 5 symptoms in childhood were diagnosed with an antisocial disorder as an adult, in comparison to 25% of children with 6 or 7 symptoms, 29% of children with 8 or 9 symptoms, and 43% of children with greater than 10 symptoms. Another early marker of severity for children and adolescents with CD has been the presence of aggression. That is, when antisocial behavior is separated into those behaviors that can be considered aggressive (eg, bullies others, initiates physical fights) and those that are nonaggressive (eg, vandalism, lies, truant), the aggressive behaviors seem to be more stable and stronger predictors of problems continuing into adulthood.8 In addition to simply documenting the presence of aggression, there has been research suggesting that the form that the aggression takes could be important. For example, research has distinguished between reactive aggression, which occurs as an angry response to provocation or threat, and proactive aggression, which is typically unprovoked and often used for instrumental gain or dominance over others.9 Research suggests that some children with severe conduct problems only show reactive forms of aggression, whereas others show a combination of both reactive and proactive forms of aggression.10 Children showing combined forms of aggression often have more problems across development.9 Thus, research suggests that the number, severity, and degree of harm that a child’s antisocial behavior causes to others are important factors to consider as markers of risk for poor outcome. To reflect this, the diagnostic criteria for CD in the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM)1,11 have
Early Identification of Antisocial Behavior
required that the person must show at least 3 different antisocial behaviors over the past 12 months to be diagnosed with CD, and then the severity is coded as: Mild: with few symptoms beyond the diagnostic threshold and behavior that causes relative minor harm to others (eg, lying, truancy); Moderate: the number of symptoms and amount of harm to others is intermediate to those specified as “mild” or “severe”; Severe: many symptoms beyond the diagnostic threshold that cause considerable harm to others (eg, rape, use of a weapon). Childhood Onset Conduct Disorder
Another important variation in how antisocial behavior is expressed in children is the age at which the serious antisocial behavior is first displayed. Persons who begin showing behavior problems before adolescence are much more likely to continue to show problems into adulthood compared with those whose problems onset during adolescence. For example, in a birth cohort from New Zealand that was followed into adulthood, the rate of official convictions for violent acts in adulthood (before age 32) was as follows: 32.7% for males who began showing serious conduct problems before adolescence 10.2% for males who began showing serious conduct problems in adolescence .4% for males who did not show serious conduct problems in either childhood or adolescence.4 Even before adolescence, there is some indication that the younger the child begins to show serious conduct problems, the more severe and persistent his or her antisocial behavior is likely to be.12 Importantly, the age of onset of antisocial behavior may subsume some of the other behavioral patterns that predict poor outcomes. That is, age of onset is negatively associated with number of conduct problems and with the level of aggression displayed by the child.12,13 As a result of this research, the most recent editions of the DSM have also included criteria to distinguish early and late onset patterns of CD: Childhood-onset type: Individuals show at least one symptom characteristic of CD before age 10 years. Adolescent-onset type: Individuals show no symptom characteristic of CD before age 10 years.1 The different outcomes for these 2 subgroups of antisocial individuals may be due to differences in the causal processes that lead to the different trajectories.13,14 Specifically, the childhood-onset pattern seems to be more strongly related to neuropsychological (eg, deficits in executive functioning) and cognitive (eg, low intelligence) deficits. Also, children who show the childhood-onset pattern seem to show more temperamental and personality risk factors, such as impulsivity, attention deficits, and problems in emotional regulation. As a result, this group often displays attention-deficit hyperactivity disorder (ADHD), and it is possible that the presence of ADHD contributes to their poor outcomes.15 Importantly for early identification, the impulsivity and hyperactivity symptoms of ADHD often emerge before the child’s conduct problems and can be the first indicator that the child is having problems regulating their behavior and emotions.15 In contrast to this early-onset trajectory, persons whose antisocial behavior onsets in adolescence typically do not show the same number and severity of dispositional
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risk factors, like ADHD.13,14 However, they are often described as showing higher levels of rebelliousness and being more rejecting of conventional values and status hierarchies.16 As a result, youths in the adolescent-onset pathway are often considered as showing an exaggeration of the normative process of adolescent rebellion in which the adolescent engages in antisocial and delinquent behaviors as a misguided attempt to obtain a subjective sense of maturity and adult status in a way that is maladaptive (eg, breaking societal norms) but encouraged by an antisocial peer group.4 CALLOUS-UNEMOTIONAL TRAITS AND DEVELOPMENTAL PATHWAYS TO ANTISOCIAL BEHAVIOR
All of these approaches to identifying children who are at most risk for showing persistent antisocial behavior have focused on some aspect of how the antisocial behavior is expressed (ie, number, type, or onset of the behavior). However, there is another approach that focuses instead on the person’s affective and interpersonal style, similar to definitions of psychopathy in adults.17 This style has been labeled as “callous-unemotional (CU) traits” in research18 and as “limited prosocial emotions” in diagnostic criteria for CD.1 Specifically, the 5th edition of the DSM includes a specifier (ie, “With Limited Prosocial Emotions”) that can be applied to persons who meet criteria for CD but who show at least 2 of the following symptoms over an extended period of time (ie, at least 12 months) and in multiple relationships and settings:
Lack for remorse or guilt Callous-lack of empathy Unconcerned about performance in important activities Shallow or deficient affect.
These specific indicators and the diagnostic threshold of 2 symptoms were chosen based on extensive secondary data analyses across large samples of youth in different countries.19 Importantly, although only a minority (25% 30%) of children with CD meets the criteria for this specifier, this group seems to differ from other antisocial youth in many important ways.18 Differences Between Conduct Disorder with and Without Elevated CallousUnemotionalTraits
In terms of clinical importance, antisocial youth with CU traits (relative to other antisocial youth) show the following: A more stable pattern of antisocial behavior that predicts a greater likelihood of the antisocial behavior continuing into adulthood20,21 More severe aggression that results in greater harm to others22,23 Aggression that is more likely to be premeditated and instrumental (ie, for personal gain and dominance)22–24 Poorer response to many of the typical health interventions used to treat CD.25,26 Thus, the presence of elevated CU traits identifies a group of antisocial youth who are important for early intervention and treatment. In addition, there is evidence that these traits also classify a group of youth with CD who show very different genetic, cognitive, emotional, and social characteristics from other antisocial youth.18 Specifically, antisocial youth with elevated CU traits (relative to other antisocial children and adolescents): Show stronger genetic influences on their conduct problem behavior27 Show an insensitivity to punishment cues under many conditions28
Early Identification of Antisocial Behavior
View aggression as a more acceptable means for obtaining goals and place greater importance on dominance and revenge in social conflicts29 Display reduced emotional responses to cues of distress in others30,31 Show impairments in their selective attention to caregivers face in the first year of life, make less eye contact with caregivers in childhood, and attend less to the eye region in others later in life32–34 Show conduct problems that are less related to hostile and coercive parenting but are more strongly related to warm parenting35 Are more likely to associate with deviant peers, are more likely to commit crimes with peers, and are more influential in encouraging antisocial behavior in their peers.36,37 This extensive list of differences between antisocial youth with and without elevated CU traits has led to several theories proposing different causes to the antisocial behavior in the 2 groups. For example, children with serious conduct problems and elevated CU traits have a temperament that could make them more difficult to socialize (eg, less sensitive punishment) and miss early signs of distress in others (eg, reduced emotional responses to others’ distress).38 These processes can interfere with the normal development of key aspects of conscience (ie, empathy and guilt) and place the child at risk for a particularly severe and aggressive pattern of antisocial behavior. In contrast, children with childhood-onset antisocial behavior with normative levels Are highly reactive to emotional cues in others Are highly distressed by the effects of their behavior on others Display higher levels of emotional reactivity to provocation from others. They show conduct problems that are Less strongly influenced by genetic factors More strongly associated with hostile/coercive parenting.14,18 Based on these findings, it appears that children in this group show a temperament characterized by strong emotional reactivity combined with inadequate socializing experiences that lead to failure in the development of the skills needed to adequately regulate their emotional reactivity.39,40 The resulting problems in emotional regulation can result in the child committing impulsive and unplanned aggressive and antisocial acts, for which he or she may feel remorseful afterward, but for which he or she may still have difficulty controlling in the future. Implications for Research
From this brief review of research, it is clear that the distinction between antisocial youth with and without elevated CU traits may encompass several of the previous attempts to define important subgroups of children at risk for particularly severe and stable patterns of antisocial behavior. Specifically, children with elevated CU traits and conduct problems tend to show a greater number of conduct problems, more aggressive behavior, and more instrumental aggression.18 Furthermore, CU traits seem to designate a subgroup of children within those with both ADHD and early conduct problems who show distinct emotional and cognitive characteristics41 and who are at particularly high risk for later antisocial behavior.21 With respect to the latter, McMahon and colleagues21 reported that CU traits assessed in seventh grade significantly predicted adult antisocial outcomes (eg, adult arrests, adult antisocial personality symptoms) even after controlling for ADHD, oppositional defiant disorder, CD, and childhood-onset of CD. The presence of elevated CU traits seems particularly important for guiding research investigating the causes of antisocial behavior because they differentiate
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groups with very different emotional and cognitive characteristics. To illustrate this, Viding and colleagues31 reported that amygdala responses to fearful faces (relative to calm faces) were stronger in boys (ages 10–16) with conduct problems without elevated CU traits but were weaker in boys with conduct problems who were elevated on CU traits compared with controls. Thus, ignoring the differences among the 2 groups high on conduct problems would have hidden the differences with controls and led to erroneous conclusions on the potential importance of emotional responding for understanding the development of conduct problems. Another way that research on CU traits could be critical for causal theories of antisocial behavior is that it promotes an integration of research on processes in typically developing children with research on how these developmental processes can go awry and lead to problem behavior.38 As noted above, many theories to explain the differences between antisocial youth with and without elevated CU traits include processes that have long been the focus of developmental research, such as how children develop guilt, empathy, and other prosocial emotions and how children develop the skills necessary to regulate their emotions.40 Thus, causal theories for antisocial behavior can be advanced by integrating it with the vast research on conscience development and the development of emotional regulation in non-antisocial children. Furthermore, this approach to research on antisocial behavior in children and adolescents would be consistent with the research domain criteria (R-DoC) framework that is being advanced by the National Institute of Mental Health. Specifically, the R-DoC initiative was implemented to overcome some of the limitations in behaviorally based approaches to classifying mental health disorders, such as the great heterogeneity in the neurocognitive mechanisms that can lead to a single behavioral diagnosis like CD.42 As noted above, the use of CU traits seems to reduce this heterogeneity by designating groups with similar behavioral manifestations (ie, CD) but with unique profiles of neurocognitive processes.39 Furthermore, these neurocognitive profiles can be explained using the R-DoC domains, with the group without elevated CU traits showing problems in the regulation of the negative emotional valence system responsible for responses to aversive situations and contexts (eg, anxiety, frustration, and loss) and the group with elevated CU traits showing problems primarily in the systems for social processing that mediate responses to interpersonal settings, especially related to affiliation and attachment.42 Thus, advances in knowledge of the RDoC domains could be critical for guiding research on how these domains may be related to the development of antisocial behavior. Implications for Prevention and Treatment
The research on CU traits and the different developmental pathways to antisocial behavior could also have many important implications for preventing and treating CD. Existing research on effective treatments for antisocial behavior in children and adolescents highlights the need to Intervene as early in development as possible Intervene with comprehensive treatments that target many dispositional and contextual risk factors that can lead to or maintain the child’s antisocial behavior Tailor interventions to the unique needs of children and adolescents with serious antisocial behavior, because the most important targets of intervention may vary across antisocial individuals.43 Research on the differences between antisocial children and adolescents with and without elevated CU traits can advance each of these goals.
Early Identification of Antisocial Behavior
For example, as noted above, the most effective treatments for antisocial behavior intervene early in development when the child’s conduct problems are less severe.43 The research on the different developmental mechanisms leading to CD could allow interventions to target children who show temperamental vulnerabilities (eg, children who miss early cues to others’ distress or who have problems regulating their emotions) even before the serious conduct problems develop.44,45 Furthermore, parenting interventions could be modified to meet the unique needs of these children with very different temperaments.46 This ability to tailor treatments to the needs of the different youth with CD could be the most important benefit of recognizing the various developmental pathways to antisocial behavior. That is, the different characteristics associated with antisocial behavior in those with and without elevated CU traits could help in determining the most effective combination of services for an individual child or adolescent. As noted previously, children and adolescents who show significant levels of CU traits present quite a treatment challenge.18 However, despite their poor response to many traditional treatments, their antisocial behavior can be reduced when intensive treatments are tailored to their unique cognitive and emotional characteristics. For example, Hawes and Dadds26 reported that clinic-referred boys (ages 4–9) with conduct problems and elevated CU traits showed reductions in their conduct problems during the phase of a parenting intervention that focused on use of positive reinforcement to encourage prosocial behavior. This outcome would be consistent with the reward-oriented response style that appears to be characteristic of children with CU traits. Similarly, Caldwell and colleagues47 demonstrated that adolescent offenders with CU traits improved (ie, showed significant reductions in reoffending) when treated using an intensive treatment program that used reward-oriented approaches, targeted the self-interests of the adolescent, and taught empathy skills. Finally, White and colleagues48 tested the effectiveness of an intervention for adolescents in the juvenile justice system that focused on engaging the child and family in treatment and providing motivations for change that are individualized for each family and child. Results indicated that CU traits were associated with improvements in behavior over the course of treatment and with decreases in risk for reoffending at 6- and 12-month follow-ups. Thus, certain treatments can reduce the level and severity of the antisocial behavior of youths with CU traits, if they are tailored to the unique characteristics of this group. SUMMARY
In summary, severe and persistent antisocial behavior is a serious and costly mental health problem. Persistently antisocial individuals often start showing conduct problems early in development, and interventions that seek to treat these problems before they worsen are the most effective and least costly. Thus, early intervention for serious conduct problems is a critical goal for reducing the burden of antisocial behavior on individuals and society. Furthermore, research has suggested that there are likely several important causal pathways that lead to severe and persistent antisocial behavior. One pathway involves a failure to develop appropriate levels of empathy, guilt, and other aspects of conscience that leads to severe aggression that is planned and instrumental in nature. Another pathway involves a failure to develop adequate emotional regulation that leads to impulsive aggressive acts or other antisocial behaviors during periods of intense emotional arousal that interfere with the child’s ability to adequately consider the consequences of his or her behavior. These developmental
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pathways respond differently to treatment, and the most effective treatments are tailored to the unique characteristics of individuals in the various groups. This framework for understanding serious conduct problems in youths is important for guiding research by illustrating the need to use designs and statistical procedures that can capture the different associations with important causal variables across the different pathways. Furthermore, the unique pattern of neurocognitive processes underlying these different pathways fits well with the RDoC framework. As suggested by this framework, prospective studies in which children are grouped according to the different patterns of emotional, cognitive, and biological variables and then are followed to track the onset of conduct problems could be critical for advancing causal theory. Within such a research design, testing potential contextual factors that could moderate the risk for antisocial behavior in youth with certain types of neurocognitive risk could be critical for advancing interventions. For example, research suggests that warm and responsive parenting may reduce the level of CU traits in children who are temperamentally vulnerable to missing signs of distress in others.49 Such findings can be used to enhance existing treatments and lead to better outcomes for children and adolescents who heretofore have been resistant to typical mental health treatments. Finally, now that these pathways have been integrated into diagnostic criteria, it is likely that these distinctions among subgroups of youth with CD will be made more commonly in clinical settings, and research is needed to develop and test valid and cost-efficient means for making these distinctions.50 REFERENCES
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Washington, DC: American Psychiatric Association; 2013. 2. Canino G, Polanczyk G, Bauermeister JJ, et al. Does the prevalence of CD and ODD vary across cultures? Soc Psychiatry Psychiatr Epidemiol 2010;45:695–704. 3. Cohen MA, Piquero AR. New evidence on the monetary value of saving a high risk youth. J Quant Criminol 2009;25:25–49. 4. Odgers DL, Caspi A, Broadbent JM, et al. Prediction of differential adult health burden by conduct problem subtypes in males. Arch Gen Psychiatry 2007;64: 476–84. 5. Eyberg SM, Nelson MM, Boggs SR. Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. J Clin Child Adolesc Psychol 2008;37:215–37. 6. Loeber R. Antisocial behavior: more enduring than changeable? J Am Acad Child Adolesc Psychiatry 1991;30:393–7. 7. Robins LN. Deviant children grown up. Baltimore (MD): Williams and Wilkins; 1966. 8. Hyde LW, Burt SA, Shaw DS, et al. Early starting, aggressive, and/or callousunemotional? Examining the overlap and predictive utility of antisocial behavior subtypes. J Abnorm Psychol 2015;124:329–42. 9. Marsee MA, Frick PJ. Callous-unemotional traits and aggression in youth. In: Arsenio WF, Lemerise EA, editors. Emotions, aggression and morality in children. Washington, DC: American Psychological Association; 2010. p. 137–56. 10. Marsee MA, Frick PJ, Barry CT, et al. Profiles of forms and functions of selfreported aggression in three adolescent samples. Dev Psychopathol 2014;26: 705–20. 11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition. Washington, DC: American Psychiatric Association; 1994.
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12. Lahey BB, Goodman SH, Waldman ID, et al. Relation of age of onset to the type and severity of child and adolescent conduct problems. J Abnorm Child Psychol 1999;27:247–60. 13. Moffitt TE. Life-course persistent versus adolescence-limited antisocial behavior. In: Cicchetti D, Cohen DJ, editors. Developmental psychopathology, 2nd edition, vol. 3: risk, disorder, and adaptation. New York: Wiley; 2006. p. 570–98. 14. Frick PJ, Viding EM. Antisocial behavior from a developmental psychopathology perspective. Dev Psychopathol 2009;21:1111–31. 15. Waschbusch DA. A meta-analytic examination of comorbid hyperactive-impulsiveattention problems and conduct problems. Psychol Bull 2002;128:118–50. 16. Dandreaux DM, Frick PJ. Developmental pathways to conduct problems: a further test of the childhood and adolescent-onset distinction. J Abnorm Child Psychol 2009;37:375–85. 17. Hare RD, Neumann CS. Psychopath as a clinical and empirical construct. Annu Rev Clin Psychol 2008;4:217–46. 18. Frick PJ, Ray JV, Thornton LC, et al. Can callous-unemotional traits enhance the understanding, diagnosis, and treatment of serious conduct problems in children and adolescents? A comprehensive review. Psychol Bull 2014;140:1–57. 19. Kimonis ER, Fanti KA, Frick PJ, et al. Using self-reported callous-unemotional traits to cross-nationally assess the DSM-5 “With Limited Prosocial Emotions” specifier. J Child Psychol Psychiatry 2015;56:1249–61. 20. Frick PJ, Stickle TR, Dandreaux DM, et al. Callous-unemotional traits in predicting the severity and stability of conduct problems and delinquency. J Abnorm Child Psychol 2005;33:471–87. 21. McMahon RJ, Witkiewitz K, Kotler JS, Conduct Problems Prevention Research Group. Predictive validity of callous-unemotional traits measures in early adolescence with respect to multiple antisocial outcomes. J Abnorm Psychol 2010;119: 752–63. 22. Kruh IP, Frick PJ, Clements CB. Historical and personality correlates to the violence patterns of juveniles tried as adults. Crim Justice Behav 2005;32:69–96. 23. Lawing K, Frick PJ, Cruise KR. Differences in offending patterns between adolescent sex offenders high or low in callous-unemotional traits. Psychol Assess 2010; 22:298–305. 24. Frick PJ, Cornell AH, Barry CT, et al. Callous-unemotional traits and conduct problems in the prediction of conduct problem severity, aggression, and selfreport of delinquency. J Abnorm Child Psychol 2003;31:457–70. 25. Haas SM, Waschbusch DA, Pelham WE, et al. Treatment response in CP/ADHD children with callous/unemotional traits. J Abnorm Child Psychol 2011;4:541–52. 26. Hawes DJ, Dadds MR. he treatment of conduct problems in children with callousunemotional traits. J Consult Clin Psychol 2005;73:737–41. 27. Viding E, Jones AP, Frick PJ, et al. Heritability of antisocial behaviour at 9: do callous-unemotional traits matter? Dev Sci 2008;11:17–22. 28. Blair RJ, Colledge E, Murray L, et al. A selective impairment in the processing of sad and fearful expressions in children with psychopathic tendencies. J Abnorm Child Psychol 2001;29:491–8. 29. Pardini DA, Lochman JE, Frick PJ. Callous-unemotional traits and social-cognitive processes in adjudicated youths. J Am Acad Child Adolesc Psychiatry 2003;42: 364–71. 30. Kimonis ER, Frick PJ, Fazekas H, et al. Psychopathy, aggression, and the emotional processing of emotional stimuli in non-referred girls and boys. Behav Sci Law 2006;24:21–37.
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31. Viding E, Sebastian CL, Dadds MR, et al. Amygdala response to preattentive masked fear in children with conduct problems: the role of callous-unemotional traits. Am J Psychiatry 2012;169:1109–16. 32. Bedford R, Pickles A, Sharp H, et al. Reduced face preference in infancy: a developmental precursor to callous-unemotional traits? Biol Psychiatry 2015;78: 144–50. 33. Dadds MR, El Masry Y, Wimalaweera S, et al. Reduced eye gaze explains “fear blindness” in childhood psychopathic traits. J Am Acad Child Adolesc Psychiatry 2008;47:455–63. 34. Dadds MR, Jabrak J, Pasalich D, et al. Impaired attention to the eyes of attachment figures and the developmental origins of psychopathy. J Child Psychol Psychiatry 2011;52:238–45. 35. Pasalich DS, Dadds MR, Hawes DJ, et al. Do callous-unemotional traits moderate the relative importance of parental coercion versus warmth in child conduct problems? An observational study. J Child Psychol Psychiatry 2012;52:1308–15. 36. Kerr M, Van Zalk M, Stattin H. Psychopathic traits moderate peer influence on adolescent delinquency. J Child Psychol Psychiatry 2012;53:826–35. 37. Thornton LC, Frick PJ, Shulman EP, et al. Callous-unemotional traits and adolescents’ role in group crime. Law Hum Behav 2015;39:368–77. 38. Frick PJ, Ray JV, Thornton LC, et al. Annual research review: a developmental psychopathology approach to understanding callous-unemotional traits in children and adolescents with serious conduct problems. J Child Psychol Psychiatry 2014;55:532–48. 39. Blair RJR. Empathy, moral development, and aggression: a cognitive neuroscience perspective. In: Arsenio WF, Lemerise EA, editors. Emotions, aggression and morality in children. Washington, DC: American Psychological Association; 2010. p. 97–114. 40. Frick PJ, Morris AS. Temperament and developmental pathways to conduct problems. J Clin Child Adolesc Psychol 2004;33:54–68. 41. Barry CT, Frick PJ, Grooms T, et al. The importance of callous-unemotional traits for extending the concept of psychopathy to children. J Abnorm Psychol 2000; 109:335–40. 42. Insel T, Cuthbert B, Garvey M, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry 2010;167:748–51. 43. Frick PJ. Developmental pathways to conduct disorder: implication for future directions in research, assessment, and treatment. J Clin Child Adolesc Psychol 2012;42:378–89. 44. Dadds MR, Allen JL, McGregor K, et al. Callous-unemotional traits in children and mechanisms of impaired eye contact during expressions of love: a treatment target? J Child Psychol Psychiatry 2014;55:771–80. 45. Kochanska G, Kim S, Boldt LJ, et al. Promoting toddlers’ positive social-emotional outcomes in low-income families: a play-based experimental study. J Clin Child Adolesc Psychol 2013;42:700–12. 46. Kimonis ER, Armstrong K. Adapting parent-child interaction therapy to treat severe conduct problems with callous-unemotional traits: a case study. Clin Case Stud 2012;11:234–52. 47. Caldwell M, Skeem J, Salekin R, et al. Treatment response of adolescent offenders with psychopathy features: a 2-year follow-up. Crim Justice Behav 2006;33:571–96.
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48. White SF, Frick PJ, Lawing SK, et al. Callous-unemotional traits and response to functional family therapy in adolescent offenders. Behav Sci Law 2013;31: 271–85. 49. Waller R, Gardner F, Hyde LW. What are the associations between parenting, callous-unemotional traits, and antisocial behavior in youth? A systematic review of evidence. Clin Psychol Rev 2013;33:593–608. 50. Frick PJ, Ray JV. Evaluating callous-unemotional traits as a personality construct. J Pers 2015;83:710–22.
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a,b,
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KEYWORDS Antisocial behavior Early identification Treatment Callous-unemotional traits Emotional regulation Diagnosis KEY POINTS Individuals most likely to show severe and persistent antisocial behavior often begin showing severe conduct problems early in childhood. Callous-unemotional (CU) traits are characterized by a lack of guilt, a lack of empathy, a restricted display of affect, and a failure to put forth the effort to succeed in important activities. The level of CU traits seems to differentiate subgroups of children and adolescents with serious conduct problems who differ in the severity and persistence of their antisocial behavior. The level of CU traits also seems to differentiate subgroups of children and adolescents with serious conduct who have different causes to their behavior problems. Treatment is enhanced when it is tailored to the unique characteristics of antisocial youth with and without elevated CU traits.
INTRODUCTION
Antisocial behavior in children and adolescents is generally defined by behavior that violates the rights of others, such as aggression, destruction of property, and theft; or behavior that violates major age-appropriate societal norms or rules, such as truancy and running away from home.1 Serious and persistent patterns of antisocial behavior in children and adolescents form the diagnostic criteria for conduct disorder (CD),1 and CD is a critical mental health concern for several reasons: It is highly prevalent with a worldwide prevalence among children and adolescents ages 6 to 18 estimated at 3.2%.2
Disclosure Statement: The author has nothing to disclose. a Department of Psychology, Louisiana State University, Baton Rouge, LA 70802, USA; b Learning Sciences Institute of Australia, Australian Catholic University, Melbourne, VIC, Australia * Department of Psychology, Louisiana State University, Baton Rouge, LA 70802. E-mail address: [email protected] Pediatr Clin N Am 63 (2016) 861–871 http://dx.doi.org/10.1016/j.pcl.2016.06.008 pediatric.theclinics.com 0031-3955/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
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It operates at a high cost to society because of the reduced quality of life for the victims of the antisocial acts and the financial costs to the legal system that must respond to the acts that violate laws.3 It predicts a host of problems in adjustment for the person with the disorder throughout their lifespan, including mental health problems (eg, substance abuse), legal problems (eg, risk for arrest), educational problems (eg, school dropout), social problems (eg, poor marital adjustment), occupational problems (eg, poor job performance), and physical health problems (eg, poor respiratory function).4 Given the prevalence, cost, and impairment associated with CD, it is not surprising that a substantial amount of research has been conducted to understand the causes of this disorder and to use this knowledge to develop effective methods to prevent or treat it. One of the most consistent findings from this work is that interventions that seek to target a reduction in antisocial behavior are least costly and most effective if they are implemented early in childhood.5 As a result, a substantial amount of research on CD has focused on identifying early markers that predict either who will develop the disorder or who is at risk for showing the most severe and persistent forms of antisocial behavior once it develops. BEHAVIORAL APPROACHES TO EARLY IDENTIFICATION Types of Behavior Associated with Poor Outcomes
Early research attempting to identify early indicators of risk for persistent antisocial behavior focused on the frequency and severity of the behavior displayed, with severity being defined as the number and variety of different behaviors displayed by the child and the number of settings in which the child displays the behaviors.6 For example, Robins reported on a classic longitudinal study of 314 children referred to a child mental health clinic for CD symptoms and reported that the risk for showing an antisocial disorder as an adult was a linear function of the number of symptoms exhibited in childhood.7 Specifically, 15% of children with 3 to 5 symptoms in childhood were diagnosed with an antisocial disorder as an adult, in comparison to 25% of children with 6 or 7 symptoms, 29% of children with 8 or 9 symptoms, and 43% of children with greater than 10 symptoms. Another early marker of severity for children and adolescents with CD has been the presence of aggression. That is, when antisocial behavior is separated into those behaviors that can be considered aggressive (eg, bullies others, initiates physical fights) and those that are nonaggressive (eg, vandalism, lies, truant), the aggressive behaviors seem to be more stable and stronger predictors of problems continuing into adulthood.8 In addition to simply documenting the presence of aggression, there has been research suggesting that the form that the aggression takes could be important. For example, research has distinguished between reactive aggression, which occurs as an angry response to provocation or threat, and proactive aggression, which is typically unprovoked and often used for instrumental gain or dominance over others.9 Research suggests that some children with severe conduct problems only show reactive forms of aggression, whereas others show a combination of both reactive and proactive forms of aggression.10 Children showing combined forms of aggression often have more problems across development.9 Thus, research suggests that the number, severity, and degree of harm that a child’s antisocial behavior causes to others are important factors to consider as markers of risk for poor outcome. To reflect this, the diagnostic criteria for CD in the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM)1,11 have
Early Identification of Antisocial Behavior
required that the person must show at least 3 different antisocial behaviors over the past 12 months to be diagnosed with CD, and then the severity is coded as: Mild: with few symptoms beyond the diagnostic threshold and behavior that causes relative minor harm to others (eg, lying, truancy); Moderate: the number of symptoms and amount of harm to others is intermediate to those specified as “mild” or “severe”; Severe: many symptoms beyond the diagnostic threshold that cause considerable harm to others (eg, rape, use of a weapon). Childhood Onset Conduct Disorder
Another important variation in how antisocial behavior is expressed in children is the age at which the serious antisocial behavior is first displayed. Persons who begin showing behavior problems before adolescence are much more likely to continue to show problems into adulthood compared with those whose problems onset during adolescence. For example, in a birth cohort from New Zealand that was followed into adulthood, the rate of official convictions for violent acts in adulthood (before age 32) was as follows: 32.7% for males who began showing serious conduct problems before adolescence 10.2% for males who began showing serious conduct problems in adolescence .4% for males who did not show serious conduct problems in either childhood or adolescence.4 Even before adolescence, there is some indication that the younger the child begins to show serious conduct problems, the more severe and persistent his or her antisocial behavior is likely to be.12 Importantly, the age of onset of antisocial behavior may subsume some of the other behavioral patterns that predict poor outcomes. That is, age of onset is negatively associated with number of conduct problems and with the level of aggression displayed by the child.12,13 As a result of this research, the most recent editions of the DSM have also included criteria to distinguish early and late onset patterns of CD: Childhood-onset type: Individuals show at least one symptom characteristic of CD before age 10 years. Adolescent-onset type: Individuals show no symptom characteristic of CD before age 10 years.1 The different outcomes for these 2 subgroups of antisocial individuals may be due to differences in the causal processes that lead to the different trajectories.13,14 Specifically, the childhood-onset pattern seems to be more strongly related to neuropsychological (eg, deficits in executive functioning) and cognitive (eg, low intelligence) deficits. Also, children who show the childhood-onset pattern seem to show more temperamental and personality risk factors, such as impulsivity, attention deficits, and problems in emotional regulation. As a result, this group often displays attention-deficit hyperactivity disorder (ADHD), and it is possible that the presence of ADHD contributes to their poor outcomes.15 Importantly for early identification, the impulsivity and hyperactivity symptoms of ADHD often emerge before the child’s conduct problems and can be the first indicator that the child is having problems regulating their behavior and emotions.15 In contrast to this early-onset trajectory, persons whose antisocial behavior onsets in adolescence typically do not show the same number and severity of dispositional
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risk factors, like ADHD.13,14 However, they are often described as showing higher levels of rebelliousness and being more rejecting of conventional values and status hierarchies.16 As a result, youths in the adolescent-onset pathway are often considered as showing an exaggeration of the normative process of adolescent rebellion in which the adolescent engages in antisocial and delinquent behaviors as a misguided attempt to obtain a subjective sense of maturity and adult status in a way that is maladaptive (eg, breaking societal norms) but encouraged by an antisocial peer group.4 CALLOUS-UNEMOTIONAL TRAITS AND DEVELOPMENTAL PATHWAYS TO ANTISOCIAL BEHAVIOR
All of these approaches to identifying children who are at most risk for showing persistent antisocial behavior have focused on some aspect of how the antisocial behavior is expressed (ie, number, type, or onset of the behavior). However, there is another approach that focuses instead on the person’s affective and interpersonal style, similar to definitions of psychopathy in adults.17 This style has been labeled as “callous-unemotional (CU) traits” in research18 and as “limited prosocial emotions” in diagnostic criteria for CD.1 Specifically, the 5th edition of the DSM includes a specifier (ie, “With Limited Prosocial Emotions”) that can be applied to persons who meet criteria for CD but who show at least 2 of the following symptoms over an extended period of time (ie, at least 12 months) and in multiple relationships and settings:
Lack for remorse or guilt Callous-lack of empathy Unconcerned about performance in important activities Shallow or deficient affect.
These specific indicators and the diagnostic threshold of 2 symptoms were chosen based on extensive secondary data analyses across large samples of youth in different countries.19 Importantly, although only a minority (25% 30%) of children with CD meets the criteria for this specifier, this group seems to differ from other antisocial youth in many important ways.18 Differences Between Conduct Disorder with and Without Elevated CallousUnemotionalTraits
In terms of clinical importance, antisocial youth with CU traits (relative to other antisocial youth) show the following: A more stable pattern of antisocial behavior that predicts a greater likelihood of the antisocial behavior continuing into adulthood20,21 More severe aggression that results in greater harm to others22,23 Aggression that is more likely to be premeditated and instrumental (ie, for personal gain and dominance)22–24 Poorer response to many of the typical health interventions used to treat CD.25,26 Thus, the presence of elevated CU traits identifies a group of antisocial youth who are important for early intervention and treatment. In addition, there is evidence that these traits also classify a group of youth with CD who show very different genetic, cognitive, emotional, and social characteristics from other antisocial youth.18 Specifically, antisocial youth with elevated CU traits (relative to other antisocial children and adolescents): Show stronger genetic influences on their conduct problem behavior27 Show an insensitivity to punishment cues under many conditions28
Early Identification of Antisocial Behavior
View aggression as a more acceptable means for obtaining goals and place greater importance on dominance and revenge in social conflicts29 Display reduced emotional responses to cues of distress in others30,31 Show impairments in their selective attention to caregivers face in the first year of life, make less eye contact with caregivers in childhood, and attend less to the eye region in others later in life32–34 Show conduct problems that are less related to hostile and coercive parenting but are more strongly related to warm parenting35 Are more likely to associate with deviant peers, are more likely to commit crimes with peers, and are more influential in encouraging antisocial behavior in their peers.36,37 This extensive list of differences between antisocial youth with and without elevated CU traits has led to several theories proposing different causes to the antisocial behavior in the 2 groups. For example, children with serious conduct problems and elevated CU traits have a temperament that could make them more difficult to socialize (eg, less sensitive punishment) and miss early signs of distress in others (eg, reduced emotional responses to others’ distress).38 These processes can interfere with the normal development of key aspects of conscience (ie, empathy and guilt) and place the child at risk for a particularly severe and aggressive pattern of antisocial behavior. In contrast, children with childhood-onset antisocial behavior with normative levels Are highly reactive to emotional cues in others Are highly distressed by the effects of their behavior on others Display higher levels of emotional reactivity to provocation from others. They show conduct problems that are Less strongly influenced by genetic factors More strongly associated with hostile/coercive parenting.14,18 Based on these findings, it appears that children in this group show a temperament characterized by strong emotional reactivity combined with inadequate socializing experiences that lead to failure in the development of the skills needed to adequately regulate their emotional reactivity.39,40 The resulting problems in emotional regulation can result in the child committing impulsive and unplanned aggressive and antisocial acts, for which he or she may feel remorseful afterward, but for which he or she may still have difficulty controlling in the future. Implications for Research
From this brief review of research, it is clear that the distinction between antisocial youth with and without elevated CU traits may encompass several of the previous attempts to define important subgroups of children at risk for particularly severe and stable patterns of antisocial behavior. Specifically, children with elevated CU traits and conduct problems tend to show a greater number of conduct problems, more aggressive behavior, and more instrumental aggression.18 Furthermore, CU traits seem to designate a subgroup of children within those with both ADHD and early conduct problems who show distinct emotional and cognitive characteristics41 and who are at particularly high risk for later antisocial behavior.21 With respect to the latter, McMahon and colleagues21 reported that CU traits assessed in seventh grade significantly predicted adult antisocial outcomes (eg, adult arrests, adult antisocial personality symptoms) even after controlling for ADHD, oppositional defiant disorder, CD, and childhood-onset of CD. The presence of elevated CU traits seems particularly important for guiding research investigating the causes of antisocial behavior because they differentiate
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groups with very different emotional and cognitive characteristics. To illustrate this, Viding and colleagues31 reported that amygdala responses to fearful faces (relative to calm faces) were stronger in boys (ages 10–16) with conduct problems without elevated CU traits but were weaker in boys with conduct problems who were elevated on CU traits compared with controls. Thus, ignoring the differences among the 2 groups high on conduct problems would have hidden the differences with controls and led to erroneous conclusions on the potential importance of emotional responding for understanding the development of conduct problems. Another way that research on CU traits could be critical for causal theories of antisocial behavior is that it promotes an integration of research on processes in typically developing children with research on how these developmental processes can go awry and lead to problem behavior.38 As noted above, many theories to explain the differences between antisocial youth with and without elevated CU traits include processes that have long been the focus of developmental research, such as how children develop guilt, empathy, and other prosocial emotions and how children develop the skills necessary to regulate their emotions.40 Thus, causal theories for antisocial behavior can be advanced by integrating it with the vast research on conscience development and the development of emotional regulation in non-antisocial children. Furthermore, this approach to research on antisocial behavior in children and adolescents would be consistent with the research domain criteria (R-DoC) framework that is being advanced by the National Institute of Mental Health. Specifically, the R-DoC initiative was implemented to overcome some of the limitations in behaviorally based approaches to classifying mental health disorders, such as the great heterogeneity in the neurocognitive mechanisms that can lead to a single behavioral diagnosis like CD.42 As noted above, the use of CU traits seems to reduce this heterogeneity by designating groups with similar behavioral manifestations (ie, CD) but with unique profiles of neurocognitive processes.39 Furthermore, these neurocognitive profiles can be explained using the R-DoC domains, with the group without elevated CU traits showing problems in the regulation of the negative emotional valence system responsible for responses to aversive situations and contexts (eg, anxiety, frustration, and loss) and the group with elevated CU traits showing problems primarily in the systems for social processing that mediate responses to interpersonal settings, especially related to affiliation and attachment.42 Thus, advances in knowledge of the RDoC domains could be critical for guiding research on how these domains may be related to the development of antisocial behavior. Implications for Prevention and Treatment
The research on CU traits and the different developmental pathways to antisocial behavior could also have many important implications for preventing and treating CD. Existing research on effective treatments for antisocial behavior in children and adolescents highlights the need to Intervene as early in development as possible Intervene with comprehensive treatments that target many dispositional and contextual risk factors that can lead to or maintain the child’s antisocial behavior Tailor interventions to the unique needs of children and adolescents with serious antisocial behavior, because the most important targets of intervention may vary across antisocial individuals.43 Research on the differences between antisocial children and adolescents with and without elevated CU traits can advance each of these goals.
Early Identification of Antisocial Behavior
For example, as noted above, the most effective treatments for antisocial behavior intervene early in development when the child’s conduct problems are less severe.43 The research on the different developmental mechanisms leading to CD could allow interventions to target children who show temperamental vulnerabilities (eg, children who miss early cues to others’ distress or who have problems regulating their emotions) even before the serious conduct problems develop.44,45 Furthermore, parenting interventions could be modified to meet the unique needs of these children with very different temperaments.46 This ability to tailor treatments to the needs of the different youth with CD could be the most important benefit of recognizing the various developmental pathways to antisocial behavior. That is, the different characteristics associated with antisocial behavior in those with and without elevated CU traits could help in determining the most effective combination of services for an individual child or adolescent. As noted previously, children and adolescents who show significant levels of CU traits present quite a treatment challenge.18 However, despite their poor response to many traditional treatments, their antisocial behavior can be reduced when intensive treatments are tailored to their unique cognitive and emotional characteristics. For example, Hawes and Dadds26 reported that clinic-referred boys (ages 4–9) with conduct problems and elevated CU traits showed reductions in their conduct problems during the phase of a parenting intervention that focused on use of positive reinforcement to encourage prosocial behavior. This outcome would be consistent with the reward-oriented response style that appears to be characteristic of children with CU traits. Similarly, Caldwell and colleagues47 demonstrated that adolescent offenders with CU traits improved (ie, showed significant reductions in reoffending) when treated using an intensive treatment program that used reward-oriented approaches, targeted the self-interests of the adolescent, and taught empathy skills. Finally, White and colleagues48 tested the effectiveness of an intervention for adolescents in the juvenile justice system that focused on engaging the child and family in treatment and providing motivations for change that are individualized for each family and child. Results indicated that CU traits were associated with improvements in behavior over the course of treatment and with decreases in risk for reoffending at 6- and 12-month follow-ups. Thus, certain treatments can reduce the level and severity of the antisocial behavior of youths with CU traits, if they are tailored to the unique characteristics of this group. SUMMARY
In summary, severe and persistent antisocial behavior is a serious and costly mental health problem. Persistently antisocial individuals often start showing conduct problems early in development, and interventions that seek to treat these problems before they worsen are the most effective and least costly. Thus, early intervention for serious conduct problems is a critical goal for reducing the burden of antisocial behavior on individuals and society. Furthermore, research has suggested that there are likely several important causal pathways that lead to severe and persistent antisocial behavior. One pathway involves a failure to develop appropriate levels of empathy, guilt, and other aspects of conscience that leads to severe aggression that is planned and instrumental in nature. Another pathway involves a failure to develop adequate emotional regulation that leads to impulsive aggressive acts or other antisocial behaviors during periods of intense emotional arousal that interfere with the child’s ability to adequately consider the consequences of his or her behavior. These developmental
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pathways respond differently to treatment, and the most effective treatments are tailored to the unique characteristics of individuals in the various groups. This framework for understanding serious conduct problems in youths is important for guiding research by illustrating the need to use designs and statistical procedures that can capture the different associations with important causal variables across the different pathways. Furthermore, the unique pattern of neurocognitive processes underlying these different pathways fits well with the RDoC framework. As suggested by this framework, prospective studies in which children are grouped according to the different patterns of emotional, cognitive, and biological variables and then are followed to track the onset of conduct problems could be critical for advancing causal theory. Within such a research design, testing potential contextual factors that could moderate the risk for antisocial behavior in youth with certain types of neurocognitive risk could be critical for advancing interventions. For example, research suggests that warm and responsive parenting may reduce the level of CU traits in children who are temperamentally vulnerable to missing signs of distress in others.49 Such findings can be used to enhance existing treatments and lead to better outcomes for children and adolescents who heretofore have been resistant to typical mental health treatments. Finally, now that these pathways have been integrated into diagnostic criteria, it is likely that these distinctions among subgroups of youth with CD will be made more commonly in clinical settings, and research is needed to develop and test valid and cost-efficient means for making these distinctions.50 REFERENCES
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48. White SF, Frick PJ, Lawing SK, et al. Callous-unemotional traits and response to functional family therapy in adolescent offenders. Behav Sci Law 2013;31: 271–85. 49. Waller R, Gardner F, Hyde LW. What are the associations between parenting, callous-unemotional traits, and antisocial behavior in youth? A systematic review of evidence. Clin Psychol Rev 2013;33:593–608. 50. Frick PJ, Ray JV. Evaluating callous-unemotional traits as a personality construct. J Pers 2015;83:710–22.
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