The Relevance of Callous-Unemotional Traits to Working With Youth With Conduct Problems
By Eva R. Kimonis, Julia Ogg, & Sarah Fefer
Children with symptoms of oppositional– defiant and conduct disorders (ODD/CD) pose significant challenges within educational settings. The worldwide prevalence among 6–18 year olds is 3.3% for ODD and 3.2% for CD (Canino, Polanczyk, Bauermeister, Rohde, & Frick, 2010). Students with conduct problems often display aggressive and antisocial behaviors that significantly disrupt classroom activities, negatively affect peers (e.g., bullying), and may necessitate additional security or repairs to destroyed school property. Intervening with such children can be challenging when they vary widely in terms of causal and risk factors, developmental outcomes, and response to intervention. This is because there are multiple developmental pathways to conduct problems, each with unique processes (Moffitt et al., 2008). Understanding the different subtypes of conduct problems is critical to designing effective school-based interventions.
Subtypes of Conduct Problems
Although most school psychologists are familiar with conduct disorder, they may be less familiar with its subtypes. Probably the most common distinction is based on the age of onset of conduct problems, lending to the inclusion of this subtype in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR and DSM-5). The adolescent-onset subtype is diagnosed when the onset of symptoms occurs by age 10 or later. When at least one symptom emerges prior to age 10, childhood-onset CD is diagnosed, which signals high risk for lifelong impairment across multiple domains (e.g., criminal involvement, physical and mental health).
Childhood-onset conduct problems can be further disaggregated into subtypes that reflect distinct patterns of emotional reactivity. The impulsive-type is characterized by emotional dysregulation and a tendency to react impulsively with intense negative emotions, partially attributed to deficits in social information processing. These children tend to come from families with dysfunctional parenting practices or physical abuse. They are at high risk for socialization problems because they do not effectively process parental messages and internalize norms when experiencing heightened emotional arousal. Their intense unregulated displays of negative emotion also contribute to peer rejection, putting them at greater risk for school truancy and association with deviant youth.
A second pattern of childhood-onset conduct problems is attributed to low levels of emotional reactivity, described as callous–unemotional (CU) traits or interpersonal callousness. CU traits characterize children who lack empathy and guilt, and display uncaring attitudes and behaviors in relation to others' feelings and their own school performance. An estimated 12% to 46% of youth meeting diagnostic criteria for CD show significant CU traits. Boys tend to score higher on CU traits than girls; however, research on gender differences is scant. Boys and girls high on CU traits show similar behavioral manifestations (e.g., aggression and delinquency), with the exception of greater relational than overt forms of aggression among girls.
Correlates to CU Traits
Understanding the distinct correlates to CU traits can provide insight into their risk factors and intervention needs. CU traits have been attributed to a fearless temperamental style, which is reflected by research findings of insensitivity to punishment cues and low levels of the stress hormone, cortisol. Children with CU traits are also distinguished from the impulsive type by a preference for novel, exciting, and dangerous activities, proneness to boredom, and low trait anxiety. Moreover, beginning early in the developmental process, they display deficits in processing negative emotional stimuli, such as detection of fear and sadness in others. These deficits have been used to explain why attempts at socialization are ineffective—the crux of this position is that cues of victim distress (e.g., crying, fear) and parental punishment intended to discourage antisocial behaviors fail to elicit an unpleasant internal state (e.g., anxiety, guilt) in the child, resulting in weak conscience development and a path to future transgressions. This explains why children with CU traits continue to engage in behaviors for which they have been repeatedly punished.
The empirical study of CU traits originated from a desire to identify precursors to adult psychopathy. Psychopathy is a personality disorder linked to a violent and serious pattern of antisocial and criminal behavior. It is characterized by a combination of interpersonal (e.g., arrogance, manipulation), affective (e.g., lack of remorse or emotion), and behavioral (e.g., irresponsibility, impulsivity) attributes. Similar to adults with psychopathy, children displaying antisocial behavior including CU traits show a more severe, stable, and aggressive pattern of conduct problems, delinquency, and police contacts than those without CU traits. Compared with impulsive-type youth, they are also more likely to engage in proactive (i.e., instrumental, goal-oriented) aggression, bullying, and affiliate with delinquent peers. As adults, they are more likely to be diagnosed with antisocial personality disorder, engage in serious and violent crime, and experience persistent legal involvement, regardless of the severity of their conduct problems. Children scoring high on a childhood measure of psychopathy are more likely to score in the psychopathic range as adults. To illustrate, of those who obtained extremely high psychopathy scores (i.e., top 5%) at age 13, approximately one third (29%) were classified as psychopathic at age 24 (Lynam, Caspi, Moffitt, Loeber, & Stouthamer-Loeber, 2007). Whether or not childhood CU traits progress to psychopathy, it is clear that these traits put children at heightened risk for severe impairment, relative to those without CU traits.
Some studies find that clinical samples of youth with CU traits have high verbal intelligence compared to impulsive-type conduct problems; however, little is known about their academic outcomes. One study investigating academic outcomes found that 6–13-year-old Swedish boys scoring high on CU traits were less likely to be assigned to a special teacher or to experience learning difficulties, and showed better academic achievement than students low on CU traits, although differences were not statistically significant (Enebrink, Andershed, & Langstrom, 2005). Another study found no significant relation between academic outcomes and CU traits beyond what was accounted for by symptoms of attention hyperactivity disorder (ADHD) and ODD (Pardini & FIte, 2010). These findings are somewhat surprising given that lack of concern over school-related performance is one component of the assessment of CU traits.
CU Traits in DSM-5
Decades of research on youth with CU traits have contributed to the inclusion of this conduct problem subtype to the assessment of CD in DSM-5. The DSM-5 now includes a “with limited prosocial emotions” specifier capturing the essence of CU traits (APA, 2013, p. 470). At least two of four characteristics (i.e., lack of remorse or guilt, callous–lack of empathy, lack of concern about performance in school or other structured activities, and shallow or deficient affect) must be present for at least 12 months across multiple relationships and settings for this specifier to apply. It is important that school psychologists understand this specifier in order to accurately and meaningfully guide diagnosis and proper selection of interventions based on this conduct problem CU subtype.
Assessing CU Traits
School psychologists commonly assess externalizing disorders using a multisource, multimethod assessment approach that includes gathering information from parents, teachers, and students with the use of interviews, ratings, and observations. Broadband rating scales used to assess externalizing behaviors such as conduct problem symptoms are helpful in the diagnostic process to determine their level of severity and to screen for comorbidities. However, these instruments provide less information on specific CU traits (although selected items from the Achenbach System of Empirically Based Assessment can be used to screen for CU traits [Kimonis, Bagner, Linares, Blake, & Rodriguez, in press; Willoughby, Waschbusch, Propper, & Moore, 2011]). A handful of tools are available to determine the presence of CU traits. The publicly available Inventory of Callous–Unemotional Traits (ICU; Frick, 2004) aligns most directly with the DSM-5 specifier criteria. It is available in self-report form for children ages 6 years and older, and is also available in caregiver- or teacher-report forms. The 24-item ICU scale has shown acceptable internal consistency and validity of scores across a wide age range, gender, ethnicities, sample types, countries, and languages. School psychologists should consider routinely assessing CU traits among children presenting with externalizing/ undercontrolled behavior problems to assist in treatment planning.
For school professionals, gathering information relevant to intervention development is likely to be their primary focus, and functional behavioral assessment (FBA) can guide this process. FBA involves identifying antecedents and consequences for behavior, as well as replacement behaviors to encourage or teach. Kern, Benson, and Clemons (2010) provide suggestions for adapting FBAs to assess severe or covert antisocial behaviors (e.g., property destruction, stealing): tracking precursor behaviors that precede more extreme behaviors; interviewing students about life events, mood, and cognitions that may contribute to or trigger the behaviors; evaluating communication strategies that may precipitate extreme behaviors; and gathering information about environmental risk factors. Knowledge of CU traits can assist school psychologists by highlighting the specific risk factors and behaviors that may be exhibited.
CU Traits and Treatment
Three psychosocial intervention approaches have been identified as effective for youth with conduct problems: parent training, contingency management, and cognitive–behavioral skill training, with the strongest effects for parent training (Frick, 2001). However, parent training interventions and other forms of behavior therapy are less effective at improving the conduct problems of children with CU than conduct problems of children without CU. A critical component of traditional behavioral approaches (e.g., teaching caregivers effective discipline strategies such as time out) is undermined by the characteristic insensitivity to punishment among youth with CU traits. Frick (2001) warns that “uninformed and ill-conceived treatments can actually do more harm than good” (p. 597), and others assert that punishment is contraindicated for children with CU traits because they often respond by escalating levels of anger, revenge, and reactive aggression (Dadds & Salmon, 2003). Although these factors can make intervening with youth with CU traits challenging, some intervention components do improve their conduct problems, namely reward-based behavioral strategies (e.g., descriptive praise). This suggests that evidence-based interventions for conduct problems may be modified to better fit the reward-dominant response styles of children with CU traits. To illustrate, Kimonis and Armstrong's (2012) adaptation of Parent–Child Interaction Therapy (Zisser & Eyberg, 2010) to include an adjunctive token economy successfully reduced conduct problems to below clinically significant levels in a young boy with marked CU traits.
Comprehensive and individualized interventions also hold particular promise for intervening with children with CU traits. For example, a modular treatment employing parent training, school-based contingency management, family therapy, cognitive–behavioral therapy, social skills training, ADHD medication, and/or crisis management— delivered on the basis of the child's individual needs—significantly reduced CU traits across a 3-year follow-up among clinically referred children (6–11 years) diagnosed with ODD or CD (Kolko et al., 2009). A comparison of this intervention to treatment-as-usual found that CU traits did not significantly predict poorer posttreatment outcomes at follow-up after controlling for conduct problem severity (Kolko & Pardini 2010). This research challenges a long history of pessimism regarding the potential of treatment to improve outcomes for youth with CU traits and suggest that school professionals may be essential in meeting the needs of this population with comprehensive intervention needs.
Most teachers believe they are not well prepared to address severe problem behaviors (Kern et al., 2010); children with CU traits may be particularly challenging to teachers given their severe and aggressive behaviors and demonstrated insensitivity to punishment- based behavioral approaches. Frick (2001) provides several recommendations relevant to school personnel for the treatment of conduct problems. First, the conduct problem subtype must be considered since the course, outcomes, and treatment needs vary across different developmental pathways. This knowledge can be used to determine what will likely be the most effective combination and intensity of services. Second, a flexible approach to treatment is recommended, which is consistent with the use of a problem-solving model that emphasizes behavioral definitions of problems, domain-specific hypotheses about why the behavior occurs, and intervention development based on data related to generated hypotheses. Using multicomponent interventions is also important given that most significant behaviors are the result of a number of factors across systems (e.g., home and school). Finally, it is crucial to consider the sustainability of intervention implementation over time; severe behavior problems have taken years to develop and often require consistency over a long period of time to remediate (Kern et al., 2010).
Schools today are focused on improving capacity to support individual students and engage in systems-level prevention practices through a multitiered framework. These foci are relevant to supporting the heterogeneous needs of youth with conduct problems. The emphasis on early identification is important given that intervention for CU traits is more effective for younger children. For example, among very young children (M age = 3.87 years) Parent–Child Interaction Therapy, which teaches caregivers child-centered interaction that is highly rewarding to the child, has proven effective at reducing conduct problems to subclinical levels for those high on CU traits, albeit not to the same levels as children low on these traits (Kimonis et al., in press). Also, strategies recommended to prevent conduct problems, such as the use of clear rules, effective instructions, and structured behavior systems are often implemented universally within multitiered systems and align with research suggesting rewardoriented interventions as a promising approach for youth with CU traits. In contrast, punitive practices such as school suspension or detention are not likely to prevent problem behaviors among this population due to the lack of concern over school performance characteristic of youth with CU traits and their demonstrated difficulty in learning from punishment. School psychologists can provide education and support to teachers to develop effective methods to promote positive behavior among this special subpopulation.
Although the universal and supplemental approaches described above may be sufficient to meet the needs of some youth with conduct problems, it is likely that those with CU traits will require an individualized and multidimensional approach. Stickle and Frick (2002) recommend early intervention to encourage empathy development, with a focus on building warm and responsive relationships and providing increased parental monitoring and supervision versus focusing on discipline. The pioneering work of Dadds and colleagues described above suggests that the incorporation of emotional skill-building into early childhood curricula has promise for further improving the development of empathy in children with CU traits. Additionally, interventions developed from FBAs may include preventive strategies (e.g., changes in expectations, connections with community resources, changing the behaviors of adults who regularly interact with the child), replacement behavior training (e.g., prompts, skill instruction, self-management), and consequent-based strategies (e.g., avoiding reinforcing problematic behaviors, developing a crisis plan) based on the needs of each student (Kern et al., 2010). Although there are no interventions specifically designed to treat youth with CU traits, several intervention programs exist that align with guidelines for intervention with this population (e.g., recognize the developmental pathway, individualized and multidimensional intervention). Examples include the Families and Schools Together (FAST Track; Conduct Problems Prevention Research Group, 1992) program and Multi-Systemic Therapy (MST; Henggeler & Borduin, 1990).
Children with conduct problems are likely to be identified through schools, including those with CU traits who show severe, continuing, and aggressive antisocial behaviors. Children with severe conduct problems often require intensive interventions implemented in multiple settings, including school, which means that school personnel play an essential role in providing effective treatment to this population. It is important for school psychologists to be knowledgeable of conduct problem subtypes in order to effectively target prevention and intervention efforts, and guard against the use of strategies that may unintentionally exacerbate problem behaviors. For children with CU traits who are less responsive to strategies that rely on punishment, the focus of intervention should be on positive reinforcement strategies that have demonstrated efficacy.
References and Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Canino, G., Polanczyk, G., Bauermeister, J. J.,
Rohde, L. A., & Frick, P. J. (2010). Does the prevalence of CD and ODD vary across cultures? Social Psychiatry and Psychiatric Epidemiology, 45, 695–704.
Conduct Problems Prevention Research Group. (1992). A developmental and clinical model for the prevention of conduct disorder: The FAST Track program. Developmental Psychopathology, 4, 509–527.
Dadds, M. R., Cauchi, A. J., Wimalaweera, S., Hawes, D. J. & Brennan, J. (in press). Outcomes, moderators, and mediators of empathic- emotion recognition training for complex conduct problems in childhood. Psychiatry Research.
Dadds, M. R., El Masry, Y., Wimalaweera, S., & Guastella, A. J. (2008). Reduced eye gaze explains “fear blindness” in childhood psychopathic traits. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 455–463.
Dadds, M. R., & Salmon, K. (2003). Punishment insensitivity and parenting: Temperament and learning as interacting risks for antisocial behavior. Clinical Child & Family Psychology Review, 6, 69–86.
Enebrink, P., Andershed, H., & Langstrom, N. (2005). Callous unemotional traits are associated with clinical severity in referred boys with conduct problems. Nordic Journal of Psychiatry, 59, 431–440.
Frick, P. J. (2001). Effective interventions for children and adolescents with conduct disorder. Canadian Journal of Psychiatry, 46, 597–608.
Frick, P. J. (2004). Developmental pathways to conduct disorder: Implications for serving youth who show severe aggressive and antisocial behavior. Psychology in the Schools, 41, 823–834.
Frick, P. J. (2004). The Inventory of Callous- Unemotional Traits. Unpublished Rating Scale. Retrieved from http://psyc.uno.edu/Frick%20Lab/ResApps.html
Frick, P. J., Ray, J. V., Thornton, L. C., & Kahn, R. E. (2013). Can callous-unemotional traits enhance the understanding, diagnosis, and treatment of serious conduct problems in children and adolescents? A comprehensive review. Psychological Bulletin. doi:10.1037/a0033076
Hawes, D. J., & Dadds, M. R. (2005). The treatment of conduct problems in children with callous-unemotional traits. Journal of Consulting & Clinical Psychology, 73, 737–741.
Henggeler, S. W., & Borduin, C. M. (1990). Family therapy and beyond: A multisystemic approach to treating the behavior problems of children and adolescents. Pacific Grove, CA: Brooks/Cole.
Kahn, R. E., Frick, P. J., Youngstrom, E., Findling, R. L., & Youngstrom, J. K. (2012). The effects of including a callous-unemotional specifier for the diagnosis of conduct disorder. Journal of Child Psychology and Psychiatry, 53, 271–282.
Kern, L., Benson, J. L., & Clemons, N. H. (2010). Strategies for working with severe challenging and violent behavior. In G. G. Peacock, R. A. Ervin, E. J. Daly III, & K. W. Merrell (Eds.) Practical handbook of school psychology: Effective practices for the 21st century (pp. 459– 474). New York, NY: Guilford Press.
Kimonis, E. R., & Armstrong, K. (2012). Adapting parent–child interaction therapy to treat severe conduct problems with callous–unemotional traits: A case study. Clinical Case Studies. Advanced online publication.
Kimonis, E. R., Bagner, D. M., Linares, D., Blake, C. A., & Rodriguez, G. (in press). Parent training outcomes among young children with callous-unemotional conduct problems with or at-risk for developmental delay. Journal of Child & Family Studies.
Kolko, D. J., Dorn, L. D., Bukstein, O., Pardini, D. A., Holden, E. A., & Hart, J. (2009). Community vs. clinic-based modular treatment of children with early-onset ODD or CD: A clinical trial with 3-year follow-up. Journal of Abnormal Child Psychology, 37, 591–609.
Kolko, D. J., & Pardini, D. A. (2010). ODD dimensions, ADHD, and callous–unemotional traits as predictors of treatment response in children with disruptive behavior disorders. Journal of Abnormal Psychology, 119, 713–725.
Lynam, D. R., Caspi, A., Moffitt, T. E., Loeber, R., & Stouthamer-Loeber, M. (2007). Longitudinal evidence that psychopathy scores in early adolescence predict adult psychopathy. Journal of Abnormal Psychology, 116, 155.
Moffitt, T. E., Arseneault, L., Jaffee, S. R., Kim- Cohen, J., Koenen, K. C., Odgers, C. L., ... Viding, E. (2008). Research review: DSM-V conduct disorder: Research needs for an evidence base. Journal of Child Psychology & Psychiatry, 49, 3–33.
Pardini, D. A., & Fite, P. J. (2010). Symptoms of conduct disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder and callous unemotional traits as unique predictors of psychosocial maladjustment in boys: Advancing an evidence base for DSMV. Journal of the American Academy of Child & Adolescent Psychiatry, 49, 1134–1144.
Stickle, T. R., & Frick, P. J. (2002). Developmental pathways to severe antisocial behavior: Interventions for youth with callous–unemotional traits. Expert Review of Neurotherapeutics, 2, 511–522.
Willoughby, M. T., Waschbusch, D. A., Propper, C. B., & Moore, G. A. (2011). Using the ASEBA to screen for callous unemotional traits in early childhood: factor structure, temporal stability, and utility. Journal of Psychopathology and Behavioral Assessment, 33, 19–30.
Zisser, A., & Eyberg, S. M. (2010). Parent–child interaction therapy and the treatment of disruptive behavior disorders. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 179–193). New York, NY: Guilford Press.
Eva R. Kimonis, PhD, is a senior lecturer in the school of psychology at The University of New South Wales in Sydney, Australia. Her research interests include understanding risk factors for the development of callous–unemotional traits and antisocial behavior in youth, and the assessment and treatment of conduct problems with callous–unemotional traits. Julia Ogg, PhD, is an assistant professor in the school psychology program at the University of South Florida in Tampa. Her research interests include early identification and intervention for youth with externalizing behaviors. Sarah Fefer, PhD, is an assistant professor of school psychology in the department of student development at the University of Massachusetts Amherst. Her research interests include disruptive behavior and home–school collaboration.