Treatment response in CP/ADHD children with callous/unemotional traits

Primary and Secondary Variants of Callous-Unemotional Traits in Children with Conduct Problems: A Longitudinal Follow-up During Adolescence

Recent empirical work has suggested that youths with conduct problems and presenting high levels of callous-unemotional (CU) traits can be divided in two variants (i.e., primary, secondary) presenting specific characteristics and needs, but studies examining outcomes associated longitudinally with variants memberships remain scarce. Building on a previous investigation in which we identified variants of CU traits among children with conduct problems, we examined differences between groups on a wide range of behavioral/psychological, relational/social, and educational outcomes assessed during adolescence (n = 309, mean age = 17.4, SD = 0.96). When compared to those from the primary variant, youths from the secondary variant reported higher levels of conduct, opposition, attention deficit/hyperactivity and anxiety problems, had lower teacher-reported academic performance, experienced more conflictual relationships with their teachers, and were at higher risk of being victimized by their intimate partner. These results shed light on the specific clinical characteristics of children from the secondary variant that are likely to persist until adolescence. Providing these children with intensive preventive interventions targeting these long-term consequences could be particularly beneficial.

Multimodal Assessment of Emotion Dysregulation in Children with and without ADHD and Disruptive Behavior Disorders

OBJECTIVE

We sought to explore if specific domains of emotion dysregulation (emotion regulation [EREG], emotional reactivity/lability [EREL], emotion recognition/understanding [ERU], and callous-unemotional [CU] behaviors) were uniquely associated with diagnostic classifications.

METHOD

This study utilized a multimodal (parent/teacher [P/T] reports and behavioral observations) approach to examine emotion dysregulation in a sample of young children (68.7% boys; mean age = 5.47, SD = 0.77, 81.4% Latinx) with attention-deficit/hyperactivity disorder (ADHD Only; n = 46), ADHD + disruptive behavior disorders (ADHD+DBD; n = 129), and typically developing (TD) children (n = 148).

RESULTS

All three diagnostic groups were significantly different from one another on P/T reports of EREG, EREL and CU. For the ADHD+DBD group, P/T reported worse EREG and EREL, and higher mean scores of CU, compared to both ADHD Only and TD groups. The ADHD+DBD group also performed significantly worse than the TD group (but not the ADHD Only group) on observed measures of EREG, EREL and ERU. P/T reported EREG, EREL and CU for the ADHD Only group were significantly worse than the TD group. Using multinomial logistic regression, P/T reported EREG, EREL, and CU were significantly associated with diagnostic status above and beyond observed measures of emotion dysregulation. The model successfully classified children with ADHD+DBD (91.3%) and TD (95.9%); however, children in the ADHD Only group were correctly identified only 45.7% of time.

CONCLUSION

Our findings suggest that measures of emotion dysregulation may be particularly helpful in correctly identifying children with ADHD+DBD, but not necessarily children with ADHD Only.

Multi-Informant Ratings of Childhood Limited Prosocial Emotions: Mother, Father, and Teacher Perspectives

OBJECTIVE

Modest agreement between mothers', fathers', and teachers' reports of child psychopathology can cause diagnostic ambiguity. Despite this, there is little research on informant perspectives of youth's limited prosocial emotions (LPEs). We examined the relationship between mother-, father-, and teacher-reported LPE in a clinical sample of elementary school-aged children.

METHOD

The sample included 207 primarily Caucasian (n = 175, 84.5%) children (136 boys; 65.7%) aged 6-13 years (M = 8.35, SD = 2.04) referred to an outpatient child diagnostic clinic focused on externalizing problems. We report the percentage of youth meeting LPE criteria as a function of informant perspective(s). Utilizing standard scores, we report distributions of informant dyads in agreement/disagreement regarding child LPE, followed up by polynomial regressions to further interrogate the relationship between mother-, father-, and teacher-reported LPE as it relates to conduct problems (CPs).

RESULTS

The prevalence of child LPE was approximately twice as large when compared to those reported in community samples; mothers and fathers generally agreed on their child's LPE symptoms (55% agreement). Higher-order nonlinear interactions between mothers and fathers, as well as parents and teachers, emerged; discrepancies between informants, characterized by low levels of LPE reported by the child's mother, were predictive of youth at the highest risk for CPs.

CONCLUSIONS

Our findings emphasize the clinical utility of gathering multiple reports of LPE when serious CPs are suspected. It may be beneficial for clinicians to give significant consideration to teacher reported LPE when interpreting multiple-informant reports of LPE.

Does Conduct, Oppositional Defiant, and Panic Disorder Symptoms Associate with Suicidal Ideations Among African American Adolescents?

Previous studies suggest that mental illness symptoms among adolescents, such as conduct disorder, oppositional defiant disorder, and panic disorder symptoms often associate with suicidal ideations. Despite this, few studies have examined whether these mental illness symptoms associate with suicidal ideations among African American adolescents. To address these limitations, the current study examined whether conduct disorder, oppositional defiant disorder, and panic disorder symptoms associated with suicidal ideations (N = 261). Using binominal logistic regression, results suggest that conduct disorder symptoms were associated with a higher likelihood of endorsing suicidal ideations than oppositional defiant disorder symptoms. Finally, panic disorder symptoms and gender differences were not associated with suicidal ideations. Preventive efforts and psychotherapy implications are discussed.

I C U but I don't care: Callous-unemotional traits and approach-avoidance behaviour in conduct disorder

BACKGROUND AND OBJECTIVES

Conduct disorder (CD) is associated with deficits in social-emotional behaviour, such as increased levels of aggression. Callous-unemotional (CU-) traits foster those deficits and contribute to severe rates of instrumental aggression in CD. Previous studies of that increase in aggression have mainly focused on intentional aspects of behaviour. Unintentional behaviour, such as automatic approach and avoidance, has not been taken into account despite being highly relevant for behaviour. Therefore, the relevance of CU-traits for automatic actions and the feasibility of an approach-avoidance-task to measure those actions in CD-patients were investigated in a study series.

METHODS

Study 1 22 CD-patients executed an approach-avoidance task, where participants pushed or pulled pictures of emotional faces using a joystick. CU-traits were assessed via parent-report. Study 2 28 CD-patients and 19 typically developing children (TD) executed the AAT. Again, CU-traits were assessed via parent-report.

RESULTS

The AAT was a feasible instrument to measure automatic action tendencies and revealed that, while TD-children showed an avoidance bias towards angry faces, CD-patients showed a lack of automatic avoidance of anger. Across the whole sample (TD and CD combined), CU-traits predicted less threat avoidance.

LIMITATIONS

The small sample size may have limited the power to detect smaller approach-avoidance tendencies towards other emotions.

CONCLUSIONS

The findings suggest that CD is associated with a lack of automatic avoidance of social threat and that CU-traits predict that lack of avoidance. Divergent automatic threat responding might underlie the extreme levels of instrumentally aggressive behaviour observed in CD-patients with distinctive CU-traits.

Longitudinal Associations between Callous-unemotional (CU) Traits and School-based Affiliative Relationships among South Korean Children

OBJECTIVE

Callous-unemotional traits (CU) traits are characterized by low empathy, guilt, and reduced sensitivity to others' feelings, along with a reduced drive for social affiliation. However, little is known about the relationships between CU traits and social affiliation in the school context, or the influence of gender on these associations. This study tested reciprocal associations between CU traits and school-based affiliative relationships and explored gender as a potential moderator.

METHOD

The sample included South Korean children aged 10 to 12 years (N = 218, M = 11.03, SD = .65, 52% boys). Children reported on CU traits, antisocial behavior, teacher-student relationship quality, and peer affiliation. Three-wave longitudinal cross-lagged models tested reciprocal associations between CU traits and affiliation with both teachers and peers, with multi-group modeling employed to test the moderating effect of gender.

RESULTS

Higher CU traits at time 1 predicted decreases in teacher affiliation at time 2 controlling for CU traits, teacher-child affiliation, and antisocial behavior at time 1, while lower teacher-child affiliation at time 2 predicted increases in CU traits at time 3 accounting for CU traits, teacher-child affiliation, and antisocial behavior at time 2. However, there were no reciprocal associations between CU traits and teacher affiliation nor significant associations between CU traits and peer affiliation. Gender did not moderate any pathways between CU traits and teacher or peer affiliation.

CONCLUSIONS

Findings indicate CU traits may reduce teacher-child affiliation, potentially escalating risk for further increases in CU traits. Thus, teacher-child affiliation may represent an important target for school-based intervention for children with elevated CU traits regardless of gender.

Individual differences in white matter of the uncinate fasciculus and inferior fronto-occipital fasciculus: possible early biomarkers for callous-unemotional behaviors in young children with disruptive behavior problems

BACKGROUND

Callous-unemotional (CU) behaviors are important for identifying severe patterns of conduct problems (CP). One major fiber tract implicated in the development of CP is the uncinate fasciculus (UF), which connects amygdala and orbitofrontal cortex (OFC). The goals of the current study were to (a) explore differences in the white matter microstructure in the UF and other major fiber tracks between young typically developing (TD) children and those with a disruptive behavior disorder (DBD) and (b) explore, within the DBD group, whether individual differences in these white matter tracts relate to co-occurring CP and CU behaviors.

METHODS

Participants included 198 young children (69% boys, M_age  = 5.66 years; 80% Latinx; 48.5% TD). CU behaviors and CP were measured via a combination of teacher/parent ratings. Non-invasive diffusion-weighted imaging (DWI) was used to measure fractional anisotropy (FA), an indirect indicator of white matter properties.

RESULTS

Relative to TD children, children in the DBD group had reduced FA on four out of the five fiber tracks we examined (except for cingulum and right ILF), even after accounting for whole brain FA, sex, movement, parental income, and IQ. Within the DBD group, no associations were found between CP and reduced white matter integrity across any of the fiber tracks examined. However, we found that even after accounting for CP, ADHD symptomology, and a host of covariates (whole brain FA, sex, movement, parental income, and IQ), CU behaviors were independently related to reduced FA in bilateral UF and left inferior fronto-occipital fasciculus (IFOF) in the DBD group, but this was not the case for TD children.

CONCLUSIONS

Alterations in the white matter microstructure within bilateral UF and left IFOF may be biomarkers of CU behaviors, even in very young children.

Neural response to monetary loss among youth with disruptive behavior disorders and callous-unemotional traits in the ABCD study

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We leveraged the ABCD Study to derive phenotypically narrow groups of youth with DBD in the largest loss processing functional MRI study to date.

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We examined neural activity to the anticipation and receipt of monetary loss using group, dimensional, and network-level analyses.

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There were no significant differences in brain activity to loss anticipation or receipt among youth with DBD with or without CU traits.

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Null findings were confirmed with and without covariates, using alternative grouping approaches, in dimensional models, and within network-level analyses.

Etiological models highlight reduced punishment sensitivity as a core risk factor for disruptive behavior disorders (DBD) and callous-unemotional (CU) traits. The current study examined neural sensitivity to the anticipation and receipt of loss, one key aspect of punishment sensitivity, among youth with DBD, comparing those with and without CU traits. Data were obtained from the Adolescent Brain and Cognitive Development (ABCD)^SM Study (N = 11,874; Mage = 9.51; 48% female). Loss-related fMRI activity during the monetary incentive delay task was examined across 16 empirically-derived a priori brain regions (e.g., striatum, amygdala, insula, anterior cingulate cortex, medial prefrontal cortex) and compared across the following groups: (1) typically developing (n = 693); (2) DBD (n = 995), subdivided into those (3) with CU traits (DBD + CU, n = 198), and (4) without CU traits (DBD-only, n = 276). Latent variable modeling was also employed to examine network-level activity. There were no significant between-group differences in brain activity to loss anticipation or receipt. Null findings were confirmed with and without covariates, using alternative grouping approaches, and in dimensional models. Network-level analyses also demonstrated comparable activity across groups during loss anticipation and receipt. Findings suggest that differences in punishment sensitivity among youth with DBD are unrelated to loss anticipation or receipt. More precise characterizations of other aspects punishment sensitivity are needed to understand risk for DBD and CU traits.

Psychopathic Traits in Childhood: Insights from Parental Warmth and Fearless Temperament via Conscience Development

The role of psychopathic traits in predicting more serious and persistent patterns of child conduct problems has been well documented. The jointly presence of interpersonal (grandiose-deceitful), affective (e.g., callous-unemotional), and behavioral psychopathic traits (impulsive-need of stimulation) identifies a group of children at increased risk of psychosocial maladjustment. The present study aims to disentangle the underlying mechanisms by examining how early parenting (i.e., warmth) and child temperament (i.e., fearlessness) predict later psychopathic traits, via conscience development (CD). Data were collected in a large sample of children (n = 2.266; 48.5% girls), aged 3 to 6 at the onset of the study (Mage = 4.25; SD = 0.91), who were followed up one and two years later. The results showed direct effects from fearlessness to interpersonal and behavioral psychopathic traits. Parental warmth, fearless temperament, and their interaction, predicted CD, which, in turn, showed a negative effect on psychopathic traits. The indirect effects indicated significant negative mediation effects of warmth through CD on psychopathic traits, which seem to be stronger when children present lower levels of fearlessness. Overall, these results contribute to better understand the development of child psychopathic traits and provide additional insight on effective strategies that will help to restrain the potential development of a high-risk profile in early childhood.

Callous-Unemotional Traits among Adolescents with Autism Spectrum Disorder, Attention-Deficit/Hyperactivity Disorder, or Typical Development: Differences between Adolescents' and Parents' Views

This study examined parent-adolescent agreement on the callous, uncaring, and unemotional dimensions of callous-unemotional (CU) traits and the differences in adolescent-reported and parent-reported CU traits among 126 adolescents with autism spectrum disorder (ASD), 207 adolescents with attention-deficit/hyperactivity disorder (ADHD), and 203 typically developing (TD) adolescents. Adolescent-reported and parent-reported CU traits on the three dimensions of the Inventory of Callous and Unemotional Traits were obtained. The strength of CU traits and the differences between adolescent-reported and parent-reported traits were compared among the three groups using analysis of covariance. Parent-adolescent agreement was examined using intraclass correlation. The results reveal that both adolescent-reported and parent-reported callousness and uncaring traits in the ASD and ADHD groups were significantly stronger than those in the TD group. Parent-adolescent agreement on the uncaring trait was fair across the three groups, whereas that on callousness was poor across all three groups. Parent-adolescent agreement on unemotionality was fair in the TD group but poor in the ADHD and ASD groups. ASD and ADHD groups had significantly greater differences in scores reported by parents and adolescents on the callousness trait than the TD group. The parent-adolescent score differences in the uncaring trait were also larger in the ASD group than in the TD group. Thus, these results support the application of a multi-informant approach in CU trait assessment, especially for adolescents with ASD or ADHD.

A Preliminary Evaluation of the Utility of Sluggish Cognitive Tempo Symptoms in Predicting Behavioral Treatment Response in Children with Behavioral Difficulties

Interest in symptoms of sluggish cognitive tempo (SCT) has led to a number of studies evaluating how these symptoms respond to treatment commonly utilized in youths with symptoms of ADHD. No study to date, however, has examined the extent to which symptoms of SCT predict behavioral treatment response in youths across multiple domains of functioning. The current preliminary investigation integrates a number of methodological (e.g., direct observations) and analytic (e.g., Poisson regression) refinements to evaluate the extent to which symptoms of SCT predict treatment responses across multiple domains including behavioral (e.g., interruptions, rule violations), social (e.g., social skills, negative verbalizations), and severe behavioral difficulties (e.g., intentional aggression) above and beyond other demographic characteristics (e.g., symptom severity, Full Scale Intelligence Quotient [FSIQ]). A relatively small sample of 37 children, aged six to 12 years (M = 8.03, SD = 1.83, 35 males: 2 females) attending an eight week multi-component intensive behavioral treatment program for youths with behavioral difficulties participated in the current study. Baseline parental perceptions of SCT were collected prior to the initiation of treatment. Results from this preliminary investigation revealed that pre-treatment SCT symptoms only predicted a less robust treatment response to time out which was associated also with parent's perceptions of underlying working memory problems. Results revealed also that pre-treatment SCT symptoms failed to predict paraprofessional counselor's and teacher's improvement ratings of both rule following and social skills following treatment. Notably, other potential predictors (e.g., symptom severity, FSIQ) also largely failed to predict behavioral treatment response.

Cognitive and Emotional Profiles of CU Traits and Disruptive Behavior in Adolescence: a Prospective Study

In this study we followed 82-90 adolescents, 50% boys, from 15 to 16 years, investigating CU traits and disruptive behaviors as predictors of cognitive skills and arousal to emotional pictures. At age 15, CU traits were rated by adolescents and disruptive (aggregated ADHD-ODD-delinquent) behaviors were rated by parents and adolescents. At age 16, executive function, reaction time variability (RTV), IQ and arousal to negative pictures were assessed. The results showed that, with control for disruptive behaviors, CU traits predicted lower RTV, higher IQ and lower arousal to negative pictures. With control for CU traits, disruptive behaviors predicted lower spatial working memory, lower interference control and higher RTV. Our findings are of theoretical and clinical relevance as they point to highly diverging cognitive and emotional profiles of CU traits and disruptive behaviors.

Internet-Delivered Parent Training for Preschoolers with Conduct Problems: Do Callous-Unemotional Traits Moderate Efficacy and Engagement?

Recent efforts to improve access to evidence-based parent training programs using online delivery have largely neglected findings that young children with callous-unemotional (CU)-type conduct problems receive less benefit from parent training than children with conduct problems alone. The current study aimed to examine the moderating effect of child CU traits on efficacy and engagement outcomes associated with Internet-delivered Parent-Child Interaction Therapy (iPCIT) versus standard, clinic-based PCIT. Forty families (57.6% non-Hispanic Caucasian) with a 3-5 year-old (M = 3.95 years, SD = 0.9; 83.5% boys) child with a disruptive behavior disorder were randomized to either iPCIT or clinic-based PCIT. Families participated in four assessments across time; child conduct problems, global functioning and treatment responder status, and parent-rated treatment satisfaction were measured. Analyses revealed that the negative influence of CU traits on functional gains was not uniform across treatment formats. Specifically, the detrimental effect of CU traits on functional gains was significantly more pronounced among children treated with iPCIT than clinic-based PCIT. CU traits also predicted lower parental treatment satisfaction across delivery formats, but this effect was more pronounced among iPCIT parents. In contrast, CU traits did not moderate differential effects across iPCIT and clinic-based PCIT for conduct problem severity or treatment response status. Findings suggest that iPCIT is a promising treatment option for early conduct problems, particularly when access-to-care barriers exist, but that further research is needed to determine whether strategic adaptations to online programs can more optimally address the distinct needs of children with clinically significant CU traits.

Adolescent-Parent Agreement on Callous-Unemotional Traits in Adolescents with Attention-Deficit/Hyperactivity Disorder

This study examined the levels of agreement between the reports of 207 adolescents with attention-deficit/hyperactivity disorder (ADHD) and their parents regarding the adolescents' callous-unemotional (CU) traits and investigated the factors influencing adolescent-parent agreement. Adolescent-parent agreement about CU traits in three dimensions according to the Chinese version of the Inventory of Callous and Unemotional Traits was examined. The influence of demographic characteristics, comorbid conduct disorder (CD), oppositional defiant disorder (ODD), and ADHD symptoms on adolescent-parent agreement was also examined. The results indicated that adolescent-parent agreement on the CU trait of uncaringness was moderate, whereas agreement on the CU traits of callousness and unemotionality was poor. Adolescent-parent agreement on the three dimensions of CU traits varied depending on the adolescents' sex and comorbid CD and ODD symptoms as well as parental age. Therefore, multiple sources of information are required when assessing the severity of CU traits in adolescents with ADHD. The factors influencing the levels of the agreement should also be considered.

Clinical Utility of the Limited Prosocial Emotions Specifier in the Childhood-Onset Subtype of Conduct Disorder

OBJECTIVE

Clinicians may specify the diagnosis of conduct disorder (CD) as "with limited prosocial emotions" (LPE). This specifier is thought to identify youths with particularly severe and stable symptomatology. However, few studies have examined the clinical usefulness of the LPE specifier among children with childhood-onset CD. The current study examines whether the LPE specifier distinguishes children with particularly severe and persistent symptoms among those with childhood-onset CD. The study also aims to test whether the LPE specifier aids in identifying children with subclinical CD whose conduct problems are at risk of increasing.

METHOD

Two hundred sixty-four children showing at least one CD symptom before age 10 were divided based on the presence of CD and the specifier. Children with and without the specifier were compared on number of CD symptoms (assessed at study inception) and trajectory of conduct problems (assessed over 4 years). The analyses controlled for oppositional defiant and attention deficit hyperactivity symptomatology.

RESULTS

Compared with children with CD but without LPE, children with CD and the LPE specifier did not differ on likelihood of endorsing most symptoms nor on total numbers of symptoms. Moreover, they did not show a more stable pattern of conduct problems across the 4 years. Children with subclinical CD with and without the LPE specifier were also similar in terms of their symptoms, severity, and evolution of their problems.

CONCLUSIONS

Among youths with childhood-onset CD, the specifier appears to offer limited value in identifying those with particularly severe and stable CD symptomatology.

A Pilot Study of Emotional Response to Time-Out in Children With Conduct Problems and Callous-Unemotional Traits

Little research has examined how children with conduct problems and concurrent callous-unemotional traits (CPCU) emotionally and behaviorally respond to time-out. This pilot study examined the distribution and stability of emotions during time-out as well as the association between emotions and negative behaviors. Participants were 11 children (M_age = 9.8 years) with CPCU who participated in a summer treatment program designed specifically for children with CPCU. Summer treatment program counselors rated each child's emotion when time-out was first assigned and then as the time-out progressed and indicated whether the child had negative behavior during time-out. These ratings were completed for approximately 30% of time-outs that occurred. Results showed that children were mostly rated as "unemotional" or "calm" and that these emotions were relatively stable throughout time-out. Furthermore, negative behaviors were most common during time-outs when children's emotions were rated as "amused." Results provide groundwork for future research to extend upon the methods used in the current study to further examine the emotional and behavioral response to time-out in children with CPCU.

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.

The structural brain correlates of callous-unemotional traits in incarcerated male adolescents

Youth with severe conduct problems impose a significant cost on society by engaging in high levels of antisocial and aggressive behavior. Within this group, adolescents with high levels of callous- unemotional traits have been found to exhibit more severe and persistent patterns of antisocial behavior than youth with severe conduct problems but normative levels of callous-unemotional traits. Existing neuroimaging studies, along with theoretical accounts of psychopathology, suggest that dysfunction within the paralimbic cortex and limbic system may underlie elevated levels of callous-unemotional traits. The present study examines this hypothesis by investigating gray matter correlates associated with callous-unemotional traits. A sample of incarcerated male adolescents (N = 269), were assessed using voxel-based morphometry. Callous-unemotional traits were assessed using the Inventory of Callous-Unemotional traits (Frick 2004). Total callous-unemotional traits were negatively correlated with anterior temporal lobe gray matter volume (GMV). Callous traits in particular exhibited a reliable negative correlation with gray matter volume in nearly every paralimbic brain region examined. Uncaring traits were positively correlated with GMV in the orbitofrontal and anterior cingulate cortices. These findings demonstrate specific neural features within the paralimbic cortex and limbic system that accompany elevated callous-unemotional traits and serves to expand our understanding of pathophysiological mechanisms that may give rise to severe conduct problems in youth.

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Total callous-unemotional traits were negatively correlated with anterior temporal lobe gray matter volume (GMV).

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Callous traits negatively correlated with GMV in nearly every paralimbic regions examined.

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Uncaring traits were positively correlated with GMV in the orbitofrontal and anterior cingulate cortices.

Applying a Cognitive Neuroscience Perspective to Disruptive Behavior Disorders: Implications for Schools

A cognitive neuroscience perspective seeks to understand behavior, in this case disruptive behavior disorders (DBD), in terms of dysfunction in cognitive processes underpinned by neural processes. While this type of approach has clear implications for clinical mental health practice, it also has implications for school-based assessment and intervention with children and adolescents who have disruptive behavior and aggression. This review articulates a cognitive neuroscience account of DBD by discussing the neurocognitive dysfunction related to emotional empathy, threat sensitivity, reinforcement-based decision-making, and response inhibition. The potential implications for current and future classroom-based assessments and interventions for students with these deficits are discussed.

Effects of Intensive Behavioral Treatment for Children With Varying Levels of Conduct Problems and Callous-Unemotional Traits

The purpose of this study was to examine whether callous-unemotional (CU) traits moderated the effects of intensive behavior therapy in elementary school-age children with varying levels of conduct problems (CP). Both treatment response (magnitude of change between pre- and posttreatment) and treatment outcomes (likelihood of normalization from treatment) were examined. Participants were 67 children (n = 49 boys, M_age = 9.6 years) with varying levels of CP and CU who participated in an intensive 8-week summer treatment program (STP) in which behavior therapy was delivered to children in recreational and classroom settings and to parents via weekly parent training sessions. Effects of treatment were measured using parent and teacher ratings of oppositional defiant disorder (ODD), conduct disorder (CD), callous behavior, and impairment. Results showed that CU moderated treatment effects for CD and callous behavior but not ODD or impairment. The moderating effects showed some evidence that participants with high CP and high CU before treatment had better treatment responses (larger change between pre- and posttreatment) but worse treatment outcomes (lower likelihood of normalization after treatment). These results suggest that intensive treatment, such as the STP, may be necessary but not sufficient for children with CP and CU traits.

Moderation of prior exposure to trauma on the inverse relationship between callous-unemotional traits and amygdala responses to fearful expressions: an exploratory study

BACKGROUND

Previous work has shown that amygdala responsiveness to fearful expressions is inversely related to level of callous-unemotional (CU) traits (i.e. reduced guilt and empathy) in youth with conduct problems. However, some research has suggested that the relationship between pathophysiology and CU traits may be different in those youth with significant prior trauma exposure.

METHODS

In experiment 1, 72 youth with varying levels of disruptive behavior and trauma exposure performed a gender discrimination task while viewing morphed fear expressions (0, 50, 100, 150 fear) and Blood Oxygenation Level Dependent responses were recorded. In experiment 2, 66 of these youth performed the Social Goals Task, which measures self-reports of the importance of specific social goals to the participant in provoking social situations.

RESULTS

In experiment 1, a significant CU traits-by-trauma exposure interaction was observed within right amygdala; fear intensity-modulated amygdala responses negatively predicted CU traits for those youth with low levels of trauma but positively predicted CU traits for those with high levels of trauma. In experiment 2, a bootstrapped model revealed that the indirect effect of fear intensity amygdala response on social goal importance through CU traits is moderated by prior trauma exposure.

CONCLUSIONS

This study, while exploratory, indicates that the pathophysiology associated with CU traits differs in youth as a function of prior trauma exposure. These data suggest that prior trauma exposure should be considered when evaluating potential interventions for youth with high CU traits.

Response to Time-Out Among Preschoolers with Externalizing Behavior Problems: The Role of Callous-Unemotional Traits

This study examined the role of callous-unemotional (CU) traits in preschoolers with externalizing behavior problems (EBP) and their response to time-out (TO). One hundred ninety preschoolers (76% boys, M^age = 4.92) with at-risk/clinically elevated levels of EBP participated in an 8-week summer treatment program (STP-PreK). Total number of minutes spent daily in TO for intentional aggression (IA) and repeated non-compliance (RNC) were recorded during the initial (T1) and final (T2) phases of the STP-PreK. After accounting for severity of EBP and levels of TO at T1, higher levels of CU traits predicted greater total levels of TO at T2. An interaction also emerged between symptoms of oppositional defiant disorder (ODD) and CU traits in predicting IA. Specifically, greater ODD symptoms predicted fewer number of IA related TO at T2, but only for children with low CU traits. Implications for treatment are discussed.

Interpersonal Callousness from Childhood to Adolescence: Developmental Trajectories and Early Risk Factors

Youth with a callous interpersonal style, consistent with features of adult psychopathy (e.g., lack of guilt, deceitful), are at risk for exhibiting severe and protracted antisocial behaviors. However, no studies have examined changes that occur in interpersonal callousness (IC) from childhood to adolescence, and little is known about the influence of early child, social, and contextual factors on trajectories of IC. The current study examined distinct patterns of IC across childhood and adolescence and associations with early risk factors. Participants were an at-risk sample of 503 boys (56% African American) assessed annually from around ages 7-15. Analyses examined child (anger dysregulation, fearfulness), social (peer, family, maltreatment), and contextual (psychosocial adversity) factors associated with teacher-reported IC trajectories across childhood and adolescence. Using latent class growth analysis, five trajectories of IC were identified (early-onset chronic, childhood-limited, adolescent-onset, moderate, low). Approximately 10% of boys followed an early-onset chronic trajectory, and a roughly equal percent of youth followed childhood-limited trajectory (10%) or an adolescent-onset trajectory (12%) of IC across development. Specifically, half of the boys with high IC in childhood did not continue to exhibit significant levels of these features into adolescence, whereas an equal proportion of youth with low IC in childhood demonstrated increasing levels during the transition to adolescence. Boys in the early-onset chronic group were characterized by the most risk factors and were differentiated from those with childhood-limited and adolescent-onset IC only by higher conduct problems, fearlessness, and emotional abuse/neglect. Findings are discussed in terms of developmental models of IC and several avenues for early targeted interventions.

Peer Inclusion in Interventions for Children with ADHD: A Systematic Review and Meta-Analysis

Objective

To assess the effectiveness of peer inclusion in interventions to improve the social functioning of children with ADHD.

Methods

We searched four electronic databases for randomized controlled trials and controlled quasi-experimental studies that investigated peer inclusion interventions alone or combined with pharmacological treatment. Data were collected from the included studies and methodologically assessed. Meta-analyses were conducted using a random-effects model.

Results

Seventeen studies met eligibility criteria. Studies investigated interventions consisting of peer involvement and peer proximity; no study included peer mediation. Most included studies had an unclear or high risk of bias regarding inadequate reporting of randomization, blinding, and control for confounders. Meta-analyses indicated improvements in pre-post measures of social functioning for participants in peer-inclusive treatment groups. Peer inclusion was advantageous compared to treatment as usual. The benefits of peer inclusion over other therapies or medication only could not be determined. Using parents as raters for outcome measurement significantly mediated the intervention effect.

Conclusions

The evidence to support or contest the efficacy of peer inclusion interventions for children with ADHD is lacking. Future studies need to reduce risks of bias, use appropriate sample sizes, and provide detailed results to investigate the efficacy of peer inclusion interventions for children with ADHD.

Callous-unemotional traits moderate executive function in children with ASD and ADHD: A pilot event-related potential study

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Children with ASD and ADHD show varied and heterogeneous executive function (EF) profiles.

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Typical or enhanced EF has been demonstrated in individuals with callous-unemotional (CU) traits.

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We investigated the effect of CU traits on event-related potential (ERP) responses during a cued continuous performance test (CPT-OX) in children with ASD, ADHD and co-occurring ASD + ADHD.

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Children with ASD and high CU traits showed better conflict monitoring compared to children with ASD and low CU traits.

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Increased CU traits may be associated with cognitive strengths in children with ASD.

Attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are associated with varied executive function (EF) difficulties. Callous-unemotional (CU) traits, a proposed antecedent of adult psychopathy, are often associated with intact or enhanced EF. Here we test whether CU traits may therefore modulate EF in ASD and ADHD, in which EF is typically impaired. We collected CU traits and measured event-related potentials (ERPs) that index EF during a cued-continuous performance test (CPT-OX) in boys with ASD, ADHD, comorbid ASD + ADHD and typical controls. We examined attentional orienting at cues (Cue-P3), inhibitory processing at non-targets (NoGo-P3) and conflict monitoring between target and non-target trials (Go-N2 vs. NoGo-N2). In children with ASD, higher CU traits were associated with an enhanced increase in N2 amplitude in NoGo trials compared to Go trials, which suggests relatively superior conflict monitoring and a potential cognitive strength associated with CU traits. The results emphasise the importance of considering the effects of co-occurring traits in the assessment of heterogeneity of EF profiles in neurodevelopmental disorders.

Callous-Unemotional Traits Among Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD): Associations with Parenting

This study examined the extent to which positive and negative parenting relates to conduct problems (CP) and callous-unemotional (CU) traits among 172 adolescents (72 % males; Mage = 16.91 years, SD = .67) with attention-deficit/hyperactivity disorder and whether CU traits moderate the link between parenting and CP. Mothers reported on their adolescents' CP, CU traits, and their own parenting practices. Maternal behaviors were observed during a problem-solving communication task. Parents who engaged in more positive parenting (self-reported and observed) reported their adolescents as having lower levels of CU traits. No effect was found for negative parenting. Moderation analyses indicated that lower levels of positive maternal behavior was only associated with higher CP in the presence of higher levels of CU traits. Negative parenting was positively related to CP regardless of CU traits. Positive parenting, irrespective of measurement approach, uniquely relates to adolescents' CU traits while both positive and negative parenting relate to CP.

The Effects of Stimulant Medication and Training on Sports Competence Among Children With ADHD

The current study examined the relative efficacy of behavioral sports training, medication, and their combination in improving sports competence among youth with attention deficit/hyperactivity disorder (ADHD). Participants were 73 youth (74% male; 81% Hispanic) between the ages of 5 and 12 diagnosed with Diagnostic and Statistical Manual of Mental Disorders (4th ed.) ADHD enrolled in a Summer Treatment Program (STP). The study consisted of a 2 (medication: methylphenidate, placebo) × 2 (sports training: instruction and practice, recreational play) between-groups design and was conducted over a 3-week period during the STP. Sports training was conducted with a novel sport, badminton, to limit previous sport knowledge and to differentiate it from concurrent sports training that occurred within the STP. Objective and subjective measures of sports skills, knowledge, and behavior were collected. Results indicated that, relative to recreational play, brief sports training improved observed and counselor-rated measures of sports competence including sports skills, knowledge, game awareness, effort, frustration, and enjoyment. During sports training, medication incrementally improved children's observed rule following behavior and counselor-rated sportsmanship relative to placebo. In the absence of sports training, medication improved behavior, effort, and sport knowledge. Training in sports skills and rules produced the largest magnitude effects on sports-related outcomes. Therefore, skills training, rather than medication alone, should be used in conjunction with behavioral intervention to teach sports to youth with ADHD. It is recommended that medication be used only as an adjunct to highly structured sports skills training for youth who display high rates of negative behavior during sports activities.

Can Callous-Unemotional Traits be Reliably Measured in Preschoolers?

Callous-unemotional (CU) traits designate an important subgroup of antisocial individuals at risk for early-starting, severe, and persistent conduct problems, but this construct has received limited attention among young children. The current study evaluated the factor structure, psychometric properties, and validity of scores on a comprehensive measure of CU traits, the Inventory of Callous-Unemotional Traits (ICU), in relation to measures of antisocial/prosocial behavior and emotional processing, administered to preschool children. The sample included 214 boys (52 %) and girls (48 %, M age = 4.7, SD = 0.69) recruited from mainstream and high-risk preschools. Confirmatory factor analyses supported a two-factor structure including callous and uncaring dimensions from 12 of the 24 original ICU items. Scores on the parent- and teacher-reported ICU were internally consistent and combined CU scores showed expected associations with an alternate measure of CU traits and measures of empathy, prosocial behavior, conduct problems, and aggression. Preschool children high on CU traits were less accurate, relative to children scoring low, in recognizing facial expressions. They were also less attentionally engaged by images of others in distress when co-occurring conduct problems presented. Findings extend the literature by supporting the psychometric properties of the ICU among young children, and open several avenues for studying early precursors to this severe personality disturbance.

Observed callousness as a predictor of treatment outcomes in parent management training

BACKGROUND

The goal of this study was to examine how observed Callous-Unemotional (CU) behavior influenced change in externalized and internalized problems, hyperactivity, social competence, and treatment satisfaction following parent management training.

METHODS

Three hundred twenty-three children and their families received Parent Management Training-the Oregon model (PMTO). They were compared at intake and after treatment in order to examine differences in 14 treatment outcomes using hierarchical regression analyses.

RESULTS

Children with low levels of observed CU showed the greatest gains after PMTO treatment. This was evident in parent, therapist, self, and teacher reports.

CONCLUSIONS

The results indicate that it is possible to observe CU behavior among children with conduct problems, and that children with elevated levels of observed CU behavior may be in need of additional treatment or components of treatment or more intense versions of parent management treatment.

Youth with substance abuse histories exhibit dysfunctional representation of expected value during a passive avoidance task

Individuals with substance abuse (SA) histories show impairment in the computations necessary for decision-making, including expected value (EV) and prediction error (PE). Neuroimaging findings, however, have been inconsistent. Sixteen youth with (SApositive) and 29 youth without (SAnegative) substance abuse histories completed a passive avoidance task while undergoing functional MRI. The groups did not significantly differ on age, gender composition or IQ. Behavioral results indicated that SApositive youth showed significantly less learning than SAnegative youth over the task. SApositive youth show problems representing EV information when attempting to avoid sub-optimal choices in bilateral inferior frontal gyrus and striatum. Furthermore, SApositive youth showed a significantly increased differential response to reward versus punishment feedback modulated by PE in posterior cingulate cortex relative to SAnegative youth. Disrupted decision-making is likely to exacerbate SA as a failure to represent EV during the avoidance of sub-optimal choices is likely to increase the likelihood of SA. With respect to the representation of PE, future work will be needed to clarify the impact of different substances on the neural systems underpinning PE representation. Moreover, interaction of age/development and substance abuse on PE signaling will need to be explored.

Early Identification and Treatment of Antisocial Behavior

Severe and persistent antisocial behavior is a prevalent, serious, and costly mental health problem. Individuals who are most likely to show persistent antisocial behavior through adolescence and into adulthood often show patterns of severe and varied conduct problems early in childhood. Treatments that intervene early in the development of these problems are most effective and least costly. Furthermore, there appear to be several common causal pathways that differ in their genetic, emotional, cognitive, and contextual characteristics. These pathways are differentiated by the level of callous-unemotional traits displayed by the individual.

A Case Study Examining Fixed Versus Randomized Criteria for Treating a Child With Conduct Problems and Callous-Unemotional Traits

Children with conduct problems and callous unemotional traits (CPCU) seem to show a decreased response to behavioral treatment (Hawes, Price, & Dadds, 2014). It was hypothesized that children with CPCU may respond differently to behavior therapy when the target behavior criteria are fixed a priori versus when the target behavior criteria are randomly determined post hoc. A single-case study experiment was conducted as an initial step toward investigating this hypothesis. The study was conducted using a daily report card implemented in the context of an intensive behavioral summer treatment program. Results indicated that rates of negative behaviors were higher when rewards were delivered using randomly determined levels of target behaviors as compared to using fixed levels of target behaviors. Results suggest the importance of providing children with CPCU specific and predictable treatment goals when using contingency management procedures. Additional research that examines how children with CPCU react to components of behavioral treatment may help improve their response to behavior therapy.

The clinical usefulness of the new LPE specifier for subtyping adolescents with conduct disorder in the DSM 5

In DSM 5, conduct disorder (CD) has been expanded with a new specifier 'with Limited Prosocial Emotions' (LPE) in addition to the age-of-onset (AoO) subtyping, and is thought to identify a severe antisocial subgroup of CD. However, research in clinical practice has been scarce. Therefore, the current study will examine differences in clinical symptoms between subtypes of CD, based on both subtyping schemes. Subsequently, it will investigate whether the LPE specifier explains unique variance in aggression, added to the AoO subtyping. A sample of 145 adolescents with CD (51 % male, mean age 15.0) from a closed treatment institution participated in this study. CD diagnoses and AoO subtype were assessed using a structured diagnostic interview. The LPE specifier was assessed using the callous-unemotional dimension of the Youth Psychopathy Traits Inventory (YPI). Self-reported proactive and reactive aggression, rule-breaking behavior and internalizing problems within the subtypes were compared. Youth with childhood-onset CD and LPE showed significantly more aggression than adolescent-onset CD without LPE (proactive aggression: F = 3.1, p < 0.05, reactive aggression: F = 3.7, p < 0.05). Hierarchical regression revealed that the LPE specifier uniquely explained 7 % of the variance in reactive aggression, additionally to the AoO subtyping. For proactive aggression, the interaction between AoO and the LPE added 4.5 % to the explained variance. Although the LPE specifier may help to identify a more aggressive subtype of CD in adolescents, the incremental utility seems to be limited. Therefore, clinical relevance of the LPE specifier in high-risk adolescent samples still needs to be investigated thoroughly.

Assessing Callous-Unemotional Traits in Adolescents: Determining Cutoff Scores for the Inventory of Callous and Unemotional Traits

OBJECTIVE

This study aims to establish a cut score for the Inventory of Callous-Unemotional Traits, a well-validated measure of callous-unemotional (CU) traits in youth for which there is currently no cutoff score.

METHOD

We analyzed data on 634 adolescents from high schools (n = 343) and juvenile detention centers (n = 291). Participants, their parents and guardians, and their teachers and staff members reported on participants' CU traits and aggressive/violent behavior.

RESULTS

All three reports of CU traits as well as intersource composites were associated with aggression, violence, and detained status. Parent report was a better indicator compared to self-reports and teacher reports. Appropriate cut scores based on each report and composite were determined.

CONCLUSION

We recommend that information from all available informants should be used whenever possible, but when only one informant report is feasible, parent reports are preferable.

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.

Neural Mechanisms of Cognitive-Behavioral Therapy for Aggression in Children and Adolescents: Design of a Randomized Controlled Trial Within the National Institute for Mental Health Research Domain Criteria Construct of Frustrative Non-Reward

OBJECTIVE

We present the rationale and design of a randomized controlled trial of cognitive-behavioral therapy (CBT) for aggression in children and adolescents, which is conducted in response to the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) approach initiative. Specifically, the study is focused on the brain-behavior associations within the RDoC construct of frustrative non-reward. On the behavioral level, this construct is defined by reactions elicited in response to withdrawal or prevention of reward, most notably reactive aggression. This study is designed to test the functional magnetic resonance (fMRI) and electrophysiological (EEG) correlates of aggression and its reduction after CBT.

METHODS

Eighty children and adolescents with high levels of aggression across multiple traditional diagnostic categories, ages 8-16, will be randomly assigned to receive 12 sessions of CBT or 12 sessions of supportive psychotherapy. Clinical outcomes will be measured by the ratings of aggressive behavior collected at baseline, midpoint, and endpoint evaluations, and by the Improvement Score of the Clinical Global Impressions Scale assigned by an independent evaluator (blinded rater). Subjects will also perform a frustration-induction Go-NoGo task and a task of emotional face perception during fMRI scanning and EEG recording at baseline and endpoint.

RESULTS

Consistent with the NIMH strategic research priorities, if functional neuroimaging and EEG variables can identify subjects who respond to CBT for aggression, this can provide a neuroscience-based classification scheme that will improve treatment outcomes for children and adolescents with aggressive behavior.

CONCLUSIONS

Demonstrating that a change in the key nodes of the emotion regulation circuitry is associated with a reduction of reactive aggression will provide evidence to support the validity of the frustrative non-reward construct.

Associations between high callous-unemotional traits and quality of life across youths with non-conduct disorder diagnoses

Research regarding callous-unemotional (CU) traits in non-conduct disorder (CD) diagnoses is sparse. We investigated the presence of high CU traits and their associations with quality of life (QoL) in a clinically referred sample of youths with non-CD diagnoses. Parents of 1018 children referred to a child and adolescent psychiatric clinic and rated their child's CU traits and QoL. Experienced clinicians derived DSM-IV-TR diagnoses based on systematic clinical evaluations of these children. High CU traits compared to low CU traits were present in 38.5 % of the sample, and more often in boys than girls (69.4 vs. 30.6 %, p = .004), and were associated with more police contacts (12.2 vs. 3.5 %, p < .001). Logistic regression analyses revealed that those with diagnoses of autism spectrum disorder (odds ratio; OR = 1.61; 95 % CI 1.24-2.09; p < .001) and disruptive behavior disorder not otherwise specified/oppositional defiant disorder (OR = 4.98; 95 % CI 2.93-8.64; p < .001), but not attention-deficit/hyperactivity disorder (OR = 1.01; 95 % CI .79-1.31; p = .94), were more likely to have high than low CU traits. Those with anxiety/mood disorders were more likely to have low than high CU traits (OR = .59; 95 % CI .42-82; p = .002). In all diagnostic groups, high CU compared to low CU traits were associated with significantly lower QoL, while controlling for gender, age, and comorbidity. As such, high CU traits significantly modify QoL in non-CD disorders.

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.

Mediating Effect of Psychopathy on the Risk of Social Problems Among Children with ADHD Versus Sluggish Cognitive Tempo Symptoms

Sluggish cognitive tempo (SCT) has been proposed as a unique syndrome; however research examining how it is different from attention-deficit/hyperactivity disorder (ADHD) is just starting to emerge. The present study extends this research by examining how specific personality features (i.e., psychopathy) may mediate the relation between ADHD and social problems, but not between SCT and social problems. Caregivers of 198 children (6-12 years old) that presented for an inpatient psychiatric evaluation completed standardized measures of childhood behavior problems. Bootstrapped mediational analyses were performed to evaluate the mediating role of psychopathy on the relation between social problems and symptoms of ADHD versus SCT. Two sub-domains of psychopathy--impulsivity and narcissism--emerged as partial mediators for the relation between social problems and ADHD symptoms; whereas SCT symptoms were not found to be related to psychopathy after controlling for ADHD symptoms. These findings provide support for conceptualizing ADHD and SCT as discrete syndromes as well as for the mediating role of psychopathy domains on the risk of social problems among a clinical sample of youth with symptoms of ADHD.

Comorbid symptomatology moderates response to risperidone, stimulant, and parent training in children with severe aggression, disruptive behavior disorder, and attention-deficit/hyperactivity disorder

OBJECTIVE

In this study, we evaluated parent and child characteristics as predictors and moderators of response in the four-site Treatment of Severe Childhood Aggression (TOSCA) study.

METHODS

A total of 168 children with severe aggression, disruptive behavior disorder, and attention-deficit/hyperactivity disorder (ADHD) were enrolled in a 9-week trial of basic treatment (n=84, stimulant+parent training+placebo) versus augmented treatment (n=84, stimulant+parent training+risperidone). In the initial report, augmented treatment surpassed basic treatment in reducing the primary outcome of disruptive behavior (D-Total) scores. In the current study, we evaluated parent (income, education, family functioning, employment) and child variables (intelligence quotient [IQ], aggression type, comorbid symptomatology) as predictors or moderators, using linear mixed models and the MacArthur guidelines.

RESULTS

Higher scores on ADHD symptom severity and callous/unemotional traits predicted better outcome on D-Total regardless of treatment assignment. Two moderators of D-Total were found: Higher anger/irritability symptoms and lower mania scores were associated with faster response, although not better overall effect at endpoint, in the augmented but not the basic group. Several variables moderated response on secondary outcomes (ADHD severity and prosocial behavior), and were characterized by faster response, although not better outcome, in the augmented but not in the basic group. Maternal education moderated outcome on the measure of positive social behavior; children of mothers with less education benefited more from augmented treatment relative to basic than those with more education.

CONCLUSION

Although these findings require validation, they tentatively suggest that augmented treatment works equally well across the entire sample. Nevertheless, certain child characteristics may be useful indicators for the speed of response to augmented treatment.

Treatment moderators of cognitive behavior therapy to reduce aggressive behavior: a meta-analysis

Maladaptive aggression in adolescents is an increasing public health concern. Cognitive Behavior Therapy (CBT) is one of the most common and promising treatments of aggression. However, there is a lack of information on predictors of treatment response regarding CBT. Therefore, a meta-analysis was performed examining the role of predictors on treatment response of CBT. Twenty-five studies were evaluated (including 2,302 participants; 1,580 boys and 722 girls), and retrieved through searches on PubMed, PsycINFO and EMBASE. Effect sizes were calculated for studies that met inclusion criteria. Study population differences and specific CBT characteristics were examined for their explanatory power. There was substantial variation across studies in design and outcome variables. The meta-analysis showed a medium treatment effect for CBT to reduce aggression (Cohen'd = 0.50). No predictors of treatment response were found in the meta-analysis. Only two studies did examine whether proactive versus reactive aggression could be a moderator of treatment outcome, and no effect was found of this subtyping of aggression. These study results suggest that CBT is effective in reducing maladaptive aggression. Furthermore, treatment setting and duration did not seem to influence treatment effect, which shows the need for development of more cost-effective and less-invasive interventions. More research is needed on moderators of outcome of CBT, including proactive versus reactive aggression. This requires better standardization of design, predictors, and outcome measures across studies.

Assessing Callous-Unemotional Traits in Preschool Children With Disruptive Behavior Problems Using Peer Reports

The goal of this study was to examine the extent to which preschoolers with externalizing behavior problems (EBP) can identify behaviors indicative of callous-unemotional (CU) traits among their peers. Participants for this study included 86 preschool children (69% boys; Mage = 5.07 years) with at-risk or clinically elevated levels of EBP who were attending a summer treatment camp. Data collected from the children, their peers, and the counselors who worked at the summer camp examined preschoolers' social preference, likability, and behaviors indicative of CU. Parents and preschool teachers also reported on children's CU traits and severity of behavioral impairment, as well as school readiness. Peer nominations of CU traits showed (a) excellent factor structure as evidenced by clear CU items (e.g., "don't feel bad when they do something wrong") versus more prosocial items ("share," "cooperate"); (b) moderate construct validity when compared to counselor reports of the CU factor as well as preschool teacher reported ratings of CU traits and severity of behavioral impairment; and (c) good utility as evidenced by associations with peer and counselor rated social preference, likability, and school readiness measures as rated by both parents and preschool teachers. These findings indicate that as early as preschool, children with EBP can identify peers who engage in behaviors indicative of CU traits, which have significant implications for children's social status and overall school readiness.

Unemotional traits predict early processing deficit for fearful expressions in young violent offenders: an investigation using continuous flash suppression

BACKGROUND

Research evidence suggests that cognitive and neural mechanisms involved in social information processing may underlie the key aspects associated with the emergence of aggression and psychopathy. Despite extensive research in this field, it is unclear whether this deficit relates to general attentional problems or affects early stages of information processing. Therefore, the aim was to explore the link between aggression, psychopathic traits, and the early processing deficits in young antisocial violent offenders (YAVOs) and healthy controls (CTLs).

METHOD

Participants were presented with rapidly changing Mondrian-like images in one eye, while a neutral or emotional (happy, angry, fearful, disgusted, surprised, sad) face was slowly introduced to the other eye. Participants indicated the location in which the face had appeared on the screen, reflecting the time when they became aware of the stimulus. The relative processing advantage was obtained by subtracting mean reaction times for emotional from neutral faces.

RESULTS

The results indicated that individuals with higher levels of unemotional traits tended to exhibit an extensive early processing disadvantage for fearful facial expressions; this relationship was only evident in the YAVO as opposed to the CTL sample.

CONCLUSIONS

These findings indicate that an emotion processing deficit in antisocial individuals is present even at the most basic levels of processing and closely related to certain psychopathic traits. Furthermore, this early processing deficit appears to be highly specific to fearful expressions, which is consistent with predictions made by influential models of psychopathy. The clinical significance and potential implications of the results are discussed.