The prospective usefulness of callous-unemotional traits and conduct disorder in predicting treatment engagement among detained girls

Testing Three New Scoring Methods to Identify Detained Adolescent Girls with Elevated Levels of Callous-Unemotional Traits

Different scoring methods have been proposed to identify adolescents with high levels of callous-unemotional (CU) traits as measured by the Inventory of Callous-Unemotional traits (ICU). This is the first study to scrutinize the usefulness of the normative, empirical, and DSM-5 with Limited Prosocial Emotions (LPE) scoring methods in criminal justice-involved girls (N = 192). Girls (Mage = 15.74) completed the ICU and other self-report questionnaires. A diagnostic interview was used to determine the presence of conduct disorder (CD) and other psychiatric disorders. Official arrest and rearrest data were also collected. The three scoring methods designated girls with (versus without) CU traits who scored higher on various indices of past and future antisocial behavior, exhibited higher rates of (childhood-onset) CD and higher levels of psychopathic traits, and displayed lower levels of agreeableness and conscientiousness. It was only when the normative and empirical scoring methods were applied that girls with CU traits had higher rates of substance use disorders and were less anxious, depressed, and/or neurotic. In a subsample of girls with CD (N = 119), the three scoring methods captured a more severely antisocial subgroup. Other expected group differences emerged, though mainly when the normative scoring method was used. Results provided support for the clinical utility of the three scoring methods but also showed that the normative scoring method most aligns with theoretical expectations. Research is warranted to explore if this normative scoring method serves as a better categorically-defined specifier for CD than the specifier that is incorporated in the DSM-5.

Sex differences in psychiatric comorbidity and clinical presentation in youths with conduct disorder

BACKGROUND

Conduct disorder (CD) rarely occurs alone but is typically accompanied by comorbid psychiatric disorders, which complicates the clinical presentation and treatment of affected youths. The aim of this study was to investigate sex differences in comorbidity pattern in CD and to systematically explore the 'gender paradox' and 'delayed-onset pathway' hypotheses of female CD.

METHODS

As part of the FemNAT-CD multisite study, semistructured clinical interviews and rating scales were used to perform a comprehensive phenotypic characterization of 454 girls and 295 boys with CD (9-18 years), compared to 864 sex- and age-matched typically developing controls.

RESULTS

Girls with CD exhibited higher rates of current major depression, anxiety disorders, post-traumatic stress disorder and borderline personality disorder, whereas boys with CD had higher rates of current attention-deficit/hyperactivity disorder. In line with the 'gender paradox' hypothesis, relative to boys, girls with CD showed significantly more lifetime psychiatric comorbidities (incl. Alcohol Use Disorder), which were accompanied by more severe CD symptoms. Female and male youths with CD also differed significantly in their CD symptom profiles and distribution of age-of-onset subtypes of CD (i.e. fewer girls with childhood-onset CD). In line with the 'delayed-onset pathway' hypothesis, girls with adolescent-onset CD showed similar levels of dimensional psychopathology like boys with childhood-onset CD, while boys with adolescent-onset CD had the lowest levels of internalizing psychopathology.

CONCLUSIONS

Within the largest study of CD in girls performed to date, we found compelling evidence for sex differences in comorbidity patterns and clinical presentation of CD. Our findings further support aspects of the 'gender paradox' and 'delayed-onset pathway' hypotheses by showing that girls with CD had higher rates of comorbid lifetime mental disorders and functional impairments, and they usually developed CD during adolescence. These novel data on sex-specific clinical profiles of CD will be critical in informing intervention and prevention programmes.

The DSM-5 Limited Prosocial Emotions Specifier for Conduct Disorder: Comorbid Problems, Prognosis, and Antecedents

OBJECTIVE

A limited prosocial emotions (LPE) subtype of conduct disorder (CD) has been added to the DSM-5. Empirical studies on this categorically defined subtype are scarce, and existing work is predominantly cross-sectional. Hypotheses surrounding the LPE subtype that relate to comorbidity, prognosis, and developmental antecedents, and overlap with psychopathic personality, have received no or little scrutiny.

METHOD

These knowledge gaps were addressed in a community sample of 1,839 children 8 to 10 years of age who were enrolled in the study in early childhood (age 3-5 years) and were followed up in early adolescence (age 11-13 years). Parents and teachers completed questionnaires that tap theoretically and clinically relevant features.

RESULTS

Children with the LPE subtype exhibited more CD symptoms and comorbid problems, including fearlessness, and symptoms of oppositional defiant disorder and attention-deficit/hyperactivity disorder. These children were also at higher risk for future CD symptoms at the 3-year follow-up. Additionally, fearlessness, callous-unemotional traits, interpersonal traits, and harsh parenting assessed in early childhood were identified as developmental antecedents of the LPE subtype. Findings tentatively suggest that the LPE subtype is a heterogeneous group differentiated on other psychopathic personality traits.

CONCLUSION

The LPE subtype appears to identify a troubled, etiologically distinct group of children with conduct problems who are at heightened risk for future maladjustment. Findings can inform the underlying mechanisms related to the LPE subtype, and can lead to the development and improvement of prevention and intervention programs for children with conduct problems.

The DSM-5 with Limited Prosocial Emotions Specifier for Conduct Disorder: a Systematic Literature Review

DSM-5 added a categorically defined specifier (‘with Limited Prosocial Emotions’; LPE) for the diagnosis of conduct disorder (CD). This paper systematically reviews the evidence base for this specifier in children and adolescents who are diagnosed with CD. Computer-assisted searches were executed and identified 181 potentially relevant papers. Eventually, nine papers were included in this review, referring to eight unique samples. All studies constructed an LPE measure by pulling the same items from the same rating scales that were used in the development of the DSM-5 LPE specifier. The prevalence of youth with CD who met criteria for this novel LPE specifier (CD + LPE) ranged from 6.1% to 83.7%. The studies greatly varied in the features used to test the viability of the DSM-5 LPE specifier. The most commonly used features relate to severity of antisocial behavior, low neuroticism (or lack of anxiety and depression), and treatment responsiveness. Available work altogether showed that CD + LPE youth displayed higher levels of past antisocial behaviour than CD Only youth, but failed to reveal other group differences that corroborate with expectations. Effect sizes typically were in the small to moderate range, suggesting that the practical usefulness of the group differences is limited. Empirical work shows that this specifier should not be used for clinical decision-making when relying on items from measures that have been used in the development of the LPE specifier. Crucially, limitations that hallmark the few studies on the topic hamper any firm conclusion about the usefulness of the specifier.

Conduct disorder in adolescent females: current state of research and study design of the FemNAT-CD consortium

Conduct disorder (CD) is a common and highly impairing psychiatric disorder of childhood and adolescence that frequently leads to poor physical and mental health outcomes in adulthood. The prevalence of CD is substantially higher in males than females, and partly due to this, most research on this condition has used all-male or predominantly male samples. Although the number of females exhibiting CD has increased in recent decades, the majority of studies on neurobiological measures, neurocognitive phenotypes, and treatments for CD have focused on male subjects only, despite strong evidence for sex differences in the aetiology and neurobiology of CD. Here, we selectively review the existing literature on CD and related phenotypes in females, focusing in particular on sex differences in CD symptoms, patterns of psychiatric comorbidity, and callous-unemotional personality traits. We also consider studies investigating the neurobiology of CD in females, with a focus on studies using genetic, structural and functional neuroimaging, psychophysiological, and neuroendocrinological methods. We end the article by providing an overview of the study design of the FemNAT-CD consortium, an interdisciplinary, multi-level and multi-site study that explicitly focuses on CD in females, but which is also investigating sex differences in the causes, developmental course, and neurobiological correlates of CD.

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.