Treatment of conduct problem youth with interpersonal callous traits using mental models: measurement of risk and change

The Effects of Psychopathy Facets on Treatment Involvement

The current study explored the relations between patient characteristics and psychopathic traits in predicting treatment involvement. We rated treatment involvement using detailed archival clinical files of 218 individuals committed to the Massachusetts Treatment Center (MTC). Psychopathy Checklist-Revised (PCL-R) scores had been rated from a previous study on the same sample. Overall, PCL-R Facets 2 and 4 significantly predicted decreases in treatment involvement, suggesting the characteristics associated with these facets have the most disruptive effects on treatment involvement. Exploratory analyses were also conducted assessing the relations between the PCL-R facets and the individual treatment involvement components. Whereas Facet 2 significantly predicted lower levels in all three individual treatment involvement components, Facet 4 only significantly predicted lower levels in two, highlighting the differentiating effects of these facets. Identifying the components that have either positive or negative effects on treatment involvement can allow clinicians to tailor treatments to optimize treatment involvement and outcome.

Effectiveness of the online mindset intervention 'The Growth Factory' for adolescents with intellectual disabilities

BACKGROUND

This study examines participant satisfaction and effectiveness of the online mindset intervention 'The Growth Factory' (TGF) for youth with intellectual disabilities using a randomised controlled trial design.

METHOD

Youth with mild to borderline intellectual disabilities (N = 119; 12-23 years) were randomly assigned to TGF (n = 60) or control group (n = 59). Primary outcome measures were mindsets and perseverance. Secondary outcomes were empowerment, mental health problems, self-esteem, treatment motivation, therapeutic alliance and challenge seeking. Measurements were conducted at pre-test, post-test and at 3 and 6 months follow-up.

RESULTS

TGF had positive effects on perseverance, mental health problems, self-esteem and therapeutic alliance at post-test. TGF had follow-up effects on mental health problems (3 months), mindset of intelligence (3 and 6 months) and mindset of emotion and behaviour (6 months).

CONCLUSIONS

TGF offers a promising add-on intervention complementing usual care programmes accelerating improvements in mindsets and mental health in youth with intellectual disabilities.

Callous-Unemotional Traits Do Not Predict Functional Family Therapy Outcomes for Adolescents With Behavior Problems

Despite the availability of evidence-based treatment models for adolescent behavior problems, little is known about the effectiveness of these programs for adolescents with callous-unemotional (CU) traits. Defined by lack of empathy, lack of guilt, flattened affect and lack of caring, CU traits have been linked to long-term anti-social behavior and unfavorable treatment outcomes and might be negatively related to outcomes in evidence-based programs such as Functional Family Therapy (FFT). This study used a single-group pre-post evaluation design with a sample of 407 adolescents (49.1% female, mean age = 14.4 years, SD = 1.9) receiving FFT to investigate whether outcomes in FFT are predicted by CU traits and to what extent reliable changes in CU traits can be observed. The results showed that although CU traits are related to increased problem severity at baseline, they predicted neither treatment dropout nor post-treatment externalizing behavior and family functioning. CU traits were related to diminished improvement ratings, in particular with respect to parental supervision. Reductions in CU traits were observed across the time of treatment, and these were most profound among adolescents with elevated levels of CU traits at baseline. Further research should investigate whether certain evidence-based treatment components are more suited for adolescents with CU, and if the addition of specific intervention elements for reducing CU-traits could further improve outcomes for this high-risk population.

Effects of Behavioral Treatment Modified to Fit Children with Conduct Problems and Callous-Unemotional (CU) Traits

Research suggests that children with conduct problems (CP) and callous-unemotional (CU) traits show a diminished response to behavior therapy, perhaps due to a reward-oriented, punishment insensitive learning style. Children with CP and CU may benefit from personalizing behavioral treatment for them by emphasizing rewards and de-emphasizing punishments. This hypothesis was tested in a sample of 46 children (78.3% boys), ages 7.0 to 12.6 years (M = 9.3, SD = 1.4). All participants met criteria for ODD and ADHD and 63% also met criteria for CD. Participants were oversampled for high CU, but CU scores ranged from average to high. Children received four weeks of modified behavior therapy that emphasized rewards and de-emphasized punishments and four weeks of treatment as usual, which was standard behavior therapy that balanced rewards and punishments. Treatments were implemented in a summer treatment program and compared using a within-subjects design, with order of treatment counterbalanced. Disruptive behavior was equal or slightly higher in modified behavior therapy than in standard behavior therapy on point system measures, but lower on parent weekly ratings. End of treatment ratings showed both treatments produced significant improvements compared to pre-treatment ratings but did not differ from each other. Personalizing behavior therapy for children with CP and CU produced inconsistent findings relative to standard behavior therapy. Behavior therapy is likely to be a necessary part of treatment for children with CP and CU, but treatment personalization efforts may provide some benefit by addressing other deficits shown by these children.

Neutralization technique use predicts delinquency and substance use outcomes

This study was part of a larger research intervention that uses motivational interviewing (MI) as part of an in-school substance use intervention in local high schools in the greater Seattle area. Our aim was to test hypothesized relationships between marijuana use, other delinquent behavior, and neutralization techniques used by participants and determine their impact on the effectiveness of an MI-based substance use intervention. Of the 84 participants that completed Intake assessments, 60% were male and identified as an ethnic minority sample: Caucasian/White = 34%; African American/Black = 16%; Hispanic/Latin@ = 16%; Asian American/Asian = 8%; multiethnic = 8%. Forty-eight students completed Week 8 Follow Up assessments. Substance abuse was measured using the Customary Drinking and Drug Use Record (CDDR; Brown et al., 1998). Delinquency was measured using a revised version of the Late Adolescent Delinquency Scale (LADS; McCartan, 2007). Neutralization technique use was measured using a revised version of the Inventory of Neutralization Techniques (Ball, 1966; Ball, 1973; Mitchell & Dodder, 1983; Shields & Whitehall, 1994). Hierarchical linear regression analyses revealed that alcohol use at intake significantly predicted alcohol use at Week 8 Follow Up, F(1,47) = 8.503, p = .005 and accounted for approximately 16% of the model variance. Adding total neutralization to the model also yielded significant outcomes and accounted for 24% of the total variance, FΔ(2,46) = 4.835, p = .033. Data showed similar findings for marijuana, with Intake marijuana use predicting use at Week 8 Follow Up, F(1,47) = 9.542, p = .003, and accounting for approximately 18% of the model variance. Including total neutralization to this model also provided significant outcomes and accounted for 26% of the variance, FΔ(2,46) = 4.611, p = .037. Including delinquency did not significantly contribute to either regression model. Understanding these participants' cognitive strategies will be valuable in determining the most effective type of substance use treatment for each student.

A Short-Term Intervention for Adolescents with Callous-Unemotional Traits and Emotion-Processing Deficits

Introduction: Research documents a robust relation between callous-unemotional (CU) traits and impairments in emotion-processing in youth, yet few evidence-based treatments targeting these deficits exist for youth with CU traits. This study examined a novel Emotion-Processing Skills Training (EPST) to target emotion recognition and perspective-taking deficits in adolescents with CU traits through an additive design.

Methods: Fifty-six adolescents (Mage = 16.54, SD = .57, 83.9% male, 67.9% White/Caucasian) attending a voluntary residential program received treatment as usual (TAU) or the EPST intervention plus TAU (EPST + TAU) in a partially randomized trial. Assessments were conducted at four time-points, and they involved adolescent-, parent-, peer-, and staff-report. Outcomes of interest included emotion recognition, perspective-taking, CU traits, empathy, prosocial behaviors, social problems, and externalizing problems.

Results: Participants who received EPST significantly improved more on perspective-taking at post-treatment than those who only received TAU. Those who only received TAU significantly declined on self-reported empathy and prosocial behaviors from baseline to 12-week follow-up, but those who received EPST declined less or had minimal change. Participants across conditions improved on self-reported CU traits, social problems, and externalizing problems and parent-reported CU traits, social problems, and externalizing problems across time.

Discussion: The EPST intervention yielded largely comparable changes to TAU, but in some cases, EPST may have buffered participants from decline in their affective, social, and behavioral functioning. Implications for treatment of adolescents with CU traits are discussed.

The Efficacy of a Compassion-Focused Therapy–Based Intervention in Reducing Psychopathic Traits and Disruptive Behavior: A Clinical Case Study With a Juvenile Detainee

Conduct disorder (CD) is the most diagnosed psychopathological disorder in juvenile detainees. The presence of a CD diagnosis, especially when associated with psychopathic traits, contributes to a poor prognosis, high recidivism rates, and low responsivity to treatment in these youth. Although group intervention programs have proven to be effective in decreasing antisocial behavior, studies testing their efficacy in reducing psychopathic traits are scarce and limited. Moreover, there is a lack of research focused on the efficacy of individual treatment approaches specifically designed to reduce psychopathic traits and disruptive behavior in juvenile detainees. Compassion-focused therapy (CFT) shows promising results in the treatment of several psychopathological disorders. Besides, there is some theoretical support to consider CFT a suitable approach to treating juvenile detainees. However, there are no treatment programs based on CFT that are designed to target psychopathic traits and disruptive behavior in these youth. Consequently, treatment outcome research in this area is absent. This clinical case study presents the treatment of a juvenile detainee with CD, a high psychopathic profile, and a very high risk for criminal recidivism using the PSYCHOPATHY.COMP program (a 20-session individual CFT program), which was specially designed to reduce psychopathic traits and disruptive behavior. The treatment outcome data revealed a significant reduction in psychopathic traits and disruptive behavior. The treatment gains were maintained and/or increased over time (3 months after program completion). This clinical case study demonstrates the feasibility and efficacy of the PSYCHOPATHY.COMP program in reducing psychopathic traits and disruptive behavior in a juvenile detainee.

An Evolutionary Model to Conceptualize Psychopathic Traits Across Community and Forensic Male Youth

Psychopathy has been historically associated with a lack of emotion. However, some authors argue that psychopathy may represent a tendency to externalize the experience of unpleasant emotions, including shame, what could be seen as an adaptive strategy within an evolutionary framework. Nevertheless, empirical research investigating this hypothesis is scarce. Using community (n = 295) and forensic (n = 300) male youth samples and a set of self-report measures, this study tested an evolutionary model involving pathways linking the impact of harsh rearing experiences (traumatic shameful experiences and warmth and safeness experiences) to psychopathic traits, as well as the indirect effects of external shame and shame coping strategies in that association. In addition, this study tested the invariance of this model across samples. Results indicated that the impact of harsh rearing experiences was directly and indirectly (through external shame and shame coping strategies) linked with psychopathic traits. The model explained psychopathic traits in forensic and community samples, though differences in some of the pathways were found across groups. Findings offer support for conceptualizing psychopathic traits as an adaptive strategy to cope with the impact of harsh rearing experiences, opening new pathways to prevention and intervention efforts.

Study protocol: a randomized controlled trial testing the effectiveness of an online mindset intervention in adolescents with intellectual disabilities

BACKGROUND

Adolescents with intellectual disabilities have an increased risk of developing academic, social, and psychological problems compared with non-disabled peers. These difficulties might have an impact on the implicit theories-or so called mindset-of these youth. Youth with a fixed mindset believe that their attributes are static while youth with a growth mindset believe their attributes are malleable. A growth mindset can positively affect the academic and psychosocial development of youth and can be stimulated by so called 'mindset interventions'. Nevertheless, mindset interventions specifically adapted to adolescents with intellectual disabilities are non-existing.

METHODS/DESIGN

The aim of the present study is to conduct a randomized controlled trial (RCT) to test the effectiveness of the online mindset intervention "The Growth Factory" aimed to teach adolescents with intellectual disabilities a growth mindset and thereby positively impacting their psychosocial development. The RCT targets adolescents (12-23 years) with mild to borderline intellectual disabilities (IQ 50-85) admitted to residential care or special education. Participants will be individually randomized to the intervention (n = 60) or control (n = 60) group. The intervention group will individually participate in the six sessions of "The Growth Factory" and the control group will receive care as usual. Primary outcome will be mindset. Empowerment, behavior problems, self-esteem, treatment motivation, therapeutic alliance, challenge seeking, and the impact of social exclusion will be included as secondary outcome measures. Moreover, moderation (i.e., intervention satisfaction, IQ, age, baseline mindset, gender) and mediation effects will be investigated. Self-reported and mentor assessments will be administrated at baseline, post-test and at three (except mentor assessment) and six months follow-up.

DISCUSSION

This paper describes the design of a RCT examining the effectiveness of the online mindset intervention "The Growth Factory" aimed to empower adolescents with intellectual disabilities. If effective, "The Growth Factory" makes an important contribution to the treatment and psychosocial development of adolescents with intellectual disabilities in residential care and special education. Due to the online approach, implementation will be efficient and cost-effective and therefore the intervention "The Growth Factory" can be used on large scale.

TRIAL REGISTRATION

Dutch Trial Register NTR5460 . Registered 2 October 2015.

Research Review: What do we know about psychopathic traits in children?

BACKGROUND

Research on the topic of child psychopathy has advanced over the past decade increasing what we know.

METHOD

This qualitative review examines the research base for child psychopathy and emphasizes its three dimensions: grandiose-manipulative, callous-unemotional, and daring-impulsive. Literature is reviewed addressing the cognitive, emotional, motivational, personality, parenting, and biological correlates.

RESULTS

Support has emerged for the phenotypic construct of child psychopathy, while questions remain regarding definitional issues and key external correlates (e.g., reward and punishment processing, parenting, molecular genetics, brain imaging).

CONCLUSIONS

While the construct appears to be valid, future work should broaden its focus from callous unemotional traits to all three dimensions of the construct, enhance measurement precision, and examine dimension interactions. Such research could have important implications for CD specification for future versions of the DSM and ICD and speed etiological knowledge and clinical care for youth with conduct problems.

Conduct disorders and psychopathy in children and adolescents: aetiology, clinical presentation and treatment strategies of callous-unemotional traits

Conduct Disorder (CD) is a psychiatric diagnosis characterized by a repetitive and persistent pattern of behaviour in which the basic rights of others and major age-appropriate social norms or rules are violated. Callous Unemotional (CU) traits are a meaningful specifier in subtyping CD for more severe antisocial and aggressive behaviours in adult psychopathology; they represent the affective dimension of adult psychopathy, but they can be also detected in childhood and adolescence. The CU traits include lack of empathy, sense of guilt and shallow emotion, and their characterization in youth can improve our diagnostic, prognostic and therapeutic abilities. A strong genetic liability, in interaction with parenting and relevant environmental factors, can lead to elevated levels of CU traits in children. We pointed out that CU traits can be detected in early childhood, may remain stable along the adolescence, but a decrease following intensive and specialized treatment is possible. We here provide a narrative review of the available evidences on CU traits in three main domains: aetiology (encompassing genetic liability and environmental risk factors), presentation (early signs and longitudinal trajectories) and treatments.

Taxometric analyses and predictive accuracy of callous-unemotional traits regarding quality of life and behavior problems in non-conduct disorder diagnoses

Callous-unemotional (CU) traits have mainly been studied in relation to conduct disorder (CD), but can also occur in other disorder groups. However, it is unclear whether there is a clinically relevant cut-off value of levels of CU traits in predicting reduced quality of life (QoL) and clinical symptoms, and whether CU traits better fit a categorical (taxonic) or dimensional model. Parents of 979 youths referred to a child and adolescent psychiatric clinic rated their child's CU traits on the Inventory of Callous-Unemotional traits (ICU), QoL on the Kidscreen-27, and clinical symptoms on the Child Behavior Checklist. Experienced clinicians conferred DSM-IV-TR diagnoses of ADHD, ASD, anxiety/mood disorders and DBD-NOS/ODD. The ICU was also used to score the DSM-5 specifier 'with limited prosocial emotions' (LPE) of Conduct Disorder. Receiver operating characteristic (ROC) analyses revealed that the predictive accuracy of the ICU and LPE regarding QoL and clinical symptoms was poor to fair, and similar across diagnoses. A clinical cut-off point could not be defined. Taxometric analyses suggested that callous-unemotional traits on the ICU best reflect a dimension rather than taxon. More research is needed on the impact of CU traits on the functional adaptation, course, and response to treatment of non-CD conditions.

Changes in J-SOAP-II and SAVRY Scores Over the Course of Residential, Cognitive-Behavioral Treatment for Adolescent Sexual Offending

Although the Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II) and the Structured Assessment of Violence Risk in Youth (SAVRY) include an emphasis on dynamic, or modifiable factors, there has been little research on dynamic changes on these tools. To help address this gap, we compared admission and discharge scores of 163 adolescents who attended a residential, cognitive-behavioral treatment program for sexual offending. Based on reliable change indices, one half of youth showed a reliable decrease on the J-SOAP-II Dynamic Risk Total Score and one third of youth showed a reliable decrease on the SAVRY Dynamic Risk Total Score. Contrary to expectations, decreases in risk factors and increases in protective factors did not predict reduced sexual, violent nonsexual, or any reoffending. In addition, no associations were found between scores on the Psychopathy Checklist:Youth Version and levels of change. Overall, the J-SOAP-II and the SAVRY hold promise in measuring change, but further research is needed.

The Youth Psychopathic Traits Inventory: Measurement Invariance and Psychometric Properties among Portuguese Youths

The aim of the present study was to examine the psychometric properties of the Youth Psychopathic Traits Inventory (YPI) among a mixed-gender sample of 782 Portuguese youth (M = 15.87 years; SD = 1.72), in a school context. Confirmatory factor analysis revealed the expected three-factor first-order structure. Cross-gender measurement invariance and cross-sample measurement invariance using a forensic sample of institutionalized males were also confirmed. The Portuguese version of the YPI demonstrated generally adequate psychometric properties of internal consistency, mean inter-item correlation, convergent validity, discriminant validity, and criterion-related validity of statistically significant associations with conduct disorder symptoms, alcohol abuse, drug use, and unprotected sex. In terms of known-groups validity, males scored higher than females, and males from the school sample scored lower than institutionalized males. The use of the YPI among the Portuguese male and female youth population is psychometrically justified, and it can be a useful measure to identify adolescents with high levels of psychopathic traits.

Practitioner Review: Involving young people with callous unemotional traits in treatment--does it work? A systematic review

BACKGROUND

Children and adolescents with callous unemotional (CU) traits are at risk of severe and persistent antisocial behavior. It is commonly assumed that these children are difficult to treat but it has been proposed that they may benefit from being involved in interventions that go beyond typical parent training programs. This systematic review sought to answer two previously unanswered questions: do interventions involving young people reduce levels of CU traits? Do CU traits predict the effectiveness of interventions for antisocial behavior involving young people?

METHOD

Studies were included that adopted an randomized controlled trial, controlled or open trial design and that had examined whether treatment was related to reductions in CU traits or whether CU traits predicted or moderated treatment effectiveness.

RESULTS

Treatments used a range of approaches, including behavioral therapy, emotion recognition training, and multimodal interventions. 4/7 studies reported reductions in CU traits following treatment. There was a mixed pattern of findings in 15 studies that examined whether CU traits predicted treatment outcomes following interventions for antisocial behavior. In 7/15 studies, CU traits were associated with worse outcomes, although three of these studies did not provide data on baseline antisocial behavior, making it difficult to evaluate whether children with high CU traits had shown improvements relative to their own behavioral baseline, despite having the worst behavioral outcomes overall. CU traits did not predict outcomes in 7/15 studies. Finally, a single study reported that CU traits predicted an overall increased response to treatment.

CONCLUSIONS

Overall, the evidence supports the idea that children with CU traits do show reductions in both their CU traits and their antisocial behavior, but typically begin treatment with poorer premorbid functioning and can still end with higher levels of antisocial behavior. However, there is considerable scope to build on the current evidence base.

Callous-unemotional traits and the treatment of conduct problems in childhood and adolescence: a comprehensive review

The treatment of conduct problems among children and adolescents with callous-unemotional (CU) traits has been subject to much speculation; however, treatment outcome research has been surprisingly limited and findings have been mixed. This review examines the research to date in this field as it pertains to two key questions. First, are CU traits associated with clinical outcomes and processes in the family based treatment of child and adolescent conduct problems? Second, can family based intervention produce change in CU traits? Using a systematic search strategy, we identified 16 treatment outcomes studies that can be brought to bear on these questions. These studies provide strong evidence of unique associations between CU traits and risk for poor treatment outcomes, while at the same time indicating that social-learning-based parent training is capable of producing lasting improvement in CU traits, particularly when delivered early in childhood. We discuss the potential for this emerging evidence base to inform the planning and delivery of treatments for clinic-referred children with CU traits, and detail an ongoing program of translational research into the development of novel interventions for this high-risk subgroup.

Recognition of pain as another deficit in young males with high callous-unemotional traits

Prior research on callous-unemotional (CU) traits supports a deficit in recognizing fear in faces and body postures. Difficulties recognising others' emotions may impair the typical behavioural inhibition for violent behaviour. However, recent research has begun to examine other distress cues such as pain. The present study examined emotion recognition skills, including pain, of school-excluded boys aged 11-16 years (N = 50). Using dynamic faces and body poses, we examined the relation between emotion recognition and CU traits using the youth psychopathic traits inventory (YPI) and the inventory of CU traits. Violent delinquency was covaried in regression analyses. Although fearful facial and fearful bodily expressions were unrelated to CU traits, recognition of dynamic pain facial expressions was negatively related to CU traits using the YPI. The failure to replicate a fear and sad deficit are discussed in relation to previous research. Also, findings are discussed in support of a general empathy deficit for distress cues which may underlie the problem behaviour of young males with CU traits.

Ringleader bullying: association with psychopathic narcissism and theory of mind among child psychiatric inpatients

This study examined the association of ringleader bullying with psychopathic traits and theory of mind among 100 youth aged 10-15 (62 boys and 38 girls) receiving inpatient psychiatric services at a state facility. Results of hierarchical multiple regression analyses indicated a positive association between ringleader bullying and psychopathic narcissism, and a significant interaction effect between narcissism and theory of mind. More specifically, narcissism moderated the relationship between theory of mind and ringleader bullying such that theory of mind was positively associated with ringleader bullying when levels of narcissism were high, and theory of mind was negatively associated ringleader bullying when levels of narcissism were low. The discussion of these results focuses on the importance of developing effective treatment techniques for youth whose bullying behavior is associated with narcissistic features and social acuity.