Psychopathy as Predictor and Moderator of Multisystemic Therapy Outcomes among Adolescents Treated for Antisocial Behavior

A scoping review of randomized controlled trials of parenting and family-based interventions for 10 - 17 year-olds with severe and persistent conduct problems

PURPOSE

A scoping review of randomized controlled trials (RCTs) of parenting and family-based interventions that aim to reduce severe and persistent conduct problems among 10-17 year-olds. The review also examined feasibility for conducting a network meta-analysis of common therapy elements measured by RCTs.

MATERIALS AND METHODS

The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA- ScR). Searches were conducted in ERIC, PsycINFO, and MEDLINE without limits on publication year, language or publication country. Study methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for RCTs.

RESULTS

Twenty-five eligible RCTs were identified. The studies trialed nine interventions, with Multisystemic Therapy (MST) being the most evaluated (N = 10), followed by Functional Family Therapy (FFT, N = 4), and Treatment Foster Care Oregon (TFCO, N = 3). Only 10 of the 25 RCTs revealed treatment effect on conduct problems, including 6 of 9 MST, 1 of 4 FFT and all 3 TFCO trials.

DISCUSSION

Surprisingly few RCTs of parenting and family-based interventions have been carried out exclusively with this population. Available data suggests that MST and FFT have uncertain effectiveness for reducing severe and persistent conduct problems. While the quality of the reviewed studies was generally high, only two reported substantive data on common therapy elements.

CONCLUSION

There is need for more RCTs of parenting and family-based interventions delivered for older children and adolescents with severe and persistent conduct problems. Future RCTs should systematically measure common therapy elements with a view to advancing intervention science.

Systematic Review and Meta-Analysis: Multisystemic Therapy and Functional Family Therapy Targeting Antisocial Behavior in Adolescence

OBJECTIVE

Youth criminal justice systems are under growing pressure to reduce re-offending behavior and to support young people's health and developmental needs. This systematic review and meta-analysis sought to synthesise evidence for 2 prominent community-based interventions for delinquent and antisocial behavior, namely, multisystemic therapy (MST) and functional family therapy (FFT).

METHOD

We searched Medline, PsycInfo, Scopus, Web of Science, and Social Services Abstracts for randomized controlled trials (RCTs) and quasi-experimental studies evaluating MST/FFT. Included studies involved participants aged under 18 years; included interventions targeted delinquent/antisocial behavior, but not maltreatment. We estimated effect sizes for 6 primary outcomes, synthesising RCTs comparing MST/FFT to usual care using correlated hierarchical effects meta-analysis. We assessed risk of bias and evidence strength using best-practice tools. Given the additional resources needed to implement MST/FFT, we rated evidence strength against a minimum clinically important difference rather than a null effect. This study is registered with PROSPERO, CRD42021279736.

RESULTS

We included 35 studies for MST (16 RCTs meta-analyzed comprising 4,095 participants, 26% female) and 19 studies for FFT (7 RCTs meta-analyzed comprising 1,471 participants, 22% female). MST had a likely clinically important effect on time in out-of-home care, but no clinically important effects on other primary outcomes (delinquency, new offenses/convictions, placement in out-of-home care, substance use), with low-to-moderate evidence strength. FFT demonstrated possible clinically important effects for the number of new offenses/convictions, time in out-of-home care, and substance use, but evidence strength was low.

CONCLUSION

Contrary to reports in some evidence clearinghouses indicating that MST/FFT are supported by the highest level of evidence strength, there is limited evidence that these interventions are superior to usual care in reducing delinquent and antisocial behavior in adolescence. These findings should be viewed in the context of important methodological differences with prior reviews, including the rating of evidence strength against a minimum clinically important difference.

STUDY PREREGISTRATION INFORMATION

The effect of Multi-Systemic Therapy and Functional Family Therapy in addressing child and adolescent delinquent and/or antisocial behavior and childhood maltreatment; https://www.crd.york.ac.uk/; 279736.

Identification of treatment elements for adolescents with callous unemotional traits: a systematic narrative review

Adolescents with callous unemotional (CU) traits are at risk for poor quality-of-life outcomes such as incarceration, suicide, and psychopathy. It is currently unknown which treatments are implemented with CU adolescents specifically and which elements make up these interventions. A narrative systematic review was used to identify the treatments and common elements used with CU adolescents (12-18 years). Eligible studies were randomized controlled trials and quasi-experimental studies evaluating psychosocial interventions, delivered within a clinical context, and directed towards the adolescent or their family. Eight studies with 1291 participants were included. Significant decreases in CU traits were demonstrated only in a minority of studies. The most utilized practice elements were set goals for treatment, practice interpersonal/communication skills, prepare for termination, and teach parents skills and strategies; the most utilized process elements were formal therapy, practice exercises, important others, and flexible/adaptive. A majority of the studies did not report an implementation element. While theoretical frameworks for CU children are employed with CU adolescents, there is still uncertainty regarding their suitability for this age group. Given the limited empirical evidence, there is a critical need for further exploration.

Antisocial Personality Traits, Substance Use, and Somatization: A Brief Consideration of Their Interrelation

The relationship between antisocial personality traits and the expression of somatic symptoms has been the subject of several theoretical and empirical investigations. The present study sought to advance the understanding of the relationship between these variables by testing two moderation models. It was hypothesized that the relationship between antisocial traits and somatization would be moderated by alcohol use, such that the presence of alcohol dependence would strengthen the relationship between antisocial traits and somatization. It was also hypothesized that gender would play a moderating role in the relationship between ASPD and somatization, such that the relationship would be stronger among women than among men. These models were tested in a sample of 787 criminal offenders. Gender did not emerge as a significant moderator in the relationship between antisocial traits and somatization. Although substance use did significantly moderate the relationship between antisocial traits and somatization, the direction of the effect ran counter to expectations: among participants reporting a history of alcohol dependency, the relationship between antisocial features and somatization was diminished. The implications of these findings are discussed.

Associations of mentalization and epistemic trust with internalizing and externalizing problems in adolescence: A gender-sensitive structural equation modeling approach

INTRODUCTION

Mentalization, operationalized as reflective functioning (RF), allows individuals to interpret actions as caused by intentional mental states. Previous research highlighted the gender-specific associations between adolescents' internalizing and externalizing difficulties and mentalizing impairments. In addition, research suggested that mentalizing facilitates the creation of epistemic trust (ET) to evaluate social information as accurate, reliable, and relevant. However, few investigations explored the concurrent associations between RF, ET, and adolescent psychopathology.

METHODS

A sample of 447 Italian cisgender adolescents (57% assigned females at birth; age range 12-19 years old; Mage  = 15.54, SD = 1.98) self-reported RF (RFQY-5), ET towards mother, father, and peers (IPPA) and mental health problems (YSR-112). Gender-specific structural equation modeling explored the associations between RF, ET, and internalizing/externalizing problems.

RESULTS

Results suggested an excellent fit for the theoretical model and revealed gender-related associations. In females, findings suggest that ET mediates the association between RF and psychopathology, with indirect associations from RF through ET to lower internalizing and externalizing problems. However, in males, RF and ET display independent associations with psychopathology.

CONCLUSION

Overall, findings suggest that ET might be a transdiagnostic factor playing different roles associated with adolescent psychopathology. Indeed, links between RF and ET might help to explore gender differences in mental health problems in this developmental phase.

Treatment of childhood disruptive behavior disorders and callous-unemotional traits: a systematic review and two multilevel meta-analyses

BACKGROUND

Children with callous-unemotional (CU) traits are at high lifetime risk of antisocial behavior. It is unknown if treatments for disruptive behavior disorders are as effective for children with CU traits (DBD+CU) as those without (DBD-only), nor if treatments directly reduce CU traits. Separate multilevel meta-analyses were conducted to compare treatment effects on DBD symptoms for DBD+CU versus DBD-only children and evaluate direct treatment-related reductions in CU traits, as well as to examine moderating factors for both questions.

METHODS

We systematically searched PsycINFO, PubMed, Cochran Library (Trials), EMBASE, MEDLINE, APA PsycNet, Scopus, and Web of Science. Eligible studies were randomized controlled trials, controlled trials, and uncontrolled studies evaluating child-focused, parenting-focused, pharmacological, family-focused, or multimodal treatments.

RESULTS

Sixty studies with 9,405 participants were included (Mage  = 10.04, SDage  = 3.89 years, 25.09% female, 44.10% racial/ethnic minority). First, treatment was associated with similar reductions in DBD symptoms for DBD+CU (SMD = 1.08, 95% CI = 0.45, 1.72) and DBD-only (SMD = 1.01, 95% CI = 0.38, 1.64). However, DBD+CU started (SMD = 1.18, 95% CI = 0.57, 1.80) and ended (SMD = 0.73, p < .001; 95% CI = 0.43, 1.04) treatment with more DBD symptoms. Second, although there was no overall direct effect of treatment on CU traits (SMD = .09, 95% CI = -0.02, 0.20), there were moderating factors. Significant treatment-related reductions in CU traits were found for studies testing parenting-focused components (SMD = 0.21, 95% CI = 0.06, 0.35), using parent-reported measures (SMD = 0.16, 95% CI = 0.04, 0.28), rated as higher quality (SMD = 0.26, 95% CI = 0.13, 0.39), conducted outside the United States (SMD = 0.19, 95% CI = 0.05, 0.32), and with less than half the sample from a racial/ethnic minority group (SMD = 0.15, 95% CI = 0.002, 0.30).

CONCLUSIONS

DBD+CU children improve with treatment, but their greater DBD symptom severity requires specialized treatment modules that could be implemented alongside parenting programs. Conclusions are tempered by heterogeneity across studies and scant evidence from randomized controlled trials.

Possible Interventions for Preventing the Development of Psychopathic Traits among Children and Adolescents?

Individuals with the combination of psychopathy and severe conduct disorder often get in a lot of trouble from their early childhood, and can cause great suffering and problems for other people and their immediate environment. Their antisocial behaviour has a tendency to develop into a chronic pattern early in life, and the treatment prognosis in adulthood is poor. A large proportion of serious violent crimes in society can be attributed to this group of perpetrators. Until recently, it has been unclear whether traits of this type can be prevented or changed, so that these individuals and their surroundings can benefit from targeted treatments at an early stage. To reduce serious crime in a society, it is very important to develop effective measures for this particular group. A lack of empathy, indifference to others, and a lack of concern about their own performance appear to be key early signs in children and adolescents with persistent behavioural problems and more serious norm violations who continue into a criminal career upon reaching adulthood. These characteristics have been termed callous−unemotional (CU) traits, and they are considered to be a precursor to psychopathic traits in adulthood. In recent years, several studies have evaluated the degree to which treatments that have been proved effective for children and adolescents with severe behavioural problems also show effectiveness for children and adolescents with CU traits. Interventions specifically tailored to children with CU traits have also been developed with the aim of directly changing the ongoing development of this precursor to psychopathy. In this paper, we will address the extent to which current evidence-based treatment methods developed for children and adolescents with behavioural difficulties are equally effective when a child has CU traits. We will also take a closer look at the effects of interventions designed to change this trait. There will be a discussion regarding what seems relevant for a change in the trait itself, as well as a change in their antisocial behaviour.

Callous-Unemotional Traits as an Intervention Target and Moderator of Parent-Child Interaction Therapy-Emotion Development Treatment for Preschool Depression and Conduct Problems

OBJECTIVE

Callous-unemotional (CU) traits-characterized by low empathy, prosociality, and guilt-predict severe and persistent conduct problems. Although some interventions for conduct problems have been less effective in children with high levels of CU traits, studies have not examined whether CU traits interfere with treatment for other childhood disorders. Moreover, few treatments have demonstrated efficacy in decreasing CU traits themselves in early childhood. This study examined whether Parent-Child Interaction Therapy-Emotion Development (PCIT-ED), a novel PCIT adaptation that promotes emotional competence with demonstrated efficacy in treating preschool-onset major depressive disorder and oppositional defiant disorder, was also effective in treating these disorders in children displaying higher levels of CU traits. The study also examined whether PCIT-ED treatment produced significant and sustained decreases in CU traits.

METHOD

This study examined 3- to 5-year-olds (N = 114) with preschool-onset major depressive disorder who completed the PCIT-ED trial. Children were randomly assigned to either immediate PCIT-ED treatment (n = 64) or a waitlist control condition (n = 50) in which they received the active treatment after 18 weeks. Psychiatric diagnoses and severity and CU traits in children were assessed at baseline, immediately after treatment, and 18 weeks after treatment completion.

RESULTS

Compared with the waitlist, PCIT-ED effectively reduced major depressive disorder and oppositional defiant disorder in preschoolers, regardless of initial levels of CU traits. Moreover, CU traits decreased from before to after treatment, and this treatment effect was sustained 18 weeks after treatment.

CONCLUSION

Results support that novel interventions that enhance emotional development display significant promise in treating CU traits-behaviors that left untreated predict severe conduct problems, criminality, and substance use.

CLINICAL TRIAL REGISTRATION INFORMATION

A Randomized Controlled Trial of PCIT-ED for Preschool Depression; https://clinicaltrials.gov; NCT02076425.

An antisocial alchemy: Psychopathic traits as a moderator of the different forms and functions of aggression in delinquency and conduct disorder among youth

The aim of the present study is to examine the possible role of psychopathic traits as a moderator of the aggression-antisociality/delinquency link. Our sample was composed of 567 youth (M = 15.91 years, SD = 0.99 years, age range = 14-18 years) from Portugal. Results indicated that psychopathic features significantly moderate four different forms and functions of aggression - proactive overt, proactive relational, reactive overt, and reactive relational - when predicting delinquency. However, psychopathic traits only significantly moderate proactive relational aggression when predicting Conduct Disorder. Psychopathic traits and aggression constitute an antisocial alchemy for antisocial behavior but more research is needed about moderation effects therein particularly among clinical and justice system involved samples of youth to inform behavioral interventions.

The Long-Term Impact of Multisystemic Therapy: An Experiential Study of the Adolescent-Young Adult Life Transition

This qualitative study examines the possible long-term impact of multisystemic therapy (MST) as young people experience the transition from adolescence to young adulthood. MST is an intensive intervention aimed at reducing antisocial behavior among young people. Interviews were conducted with 32 young people aged 16 to 22 years at their 48-month follow-up as part of the Systemic Therapy for At-Risk Teens (START) evaluation trial in the United Kingdom. Sixteen participants had received MST while 16 received management as usual (MAU). Interviews addressed participants’ current life experiences and were analyzed with interpretative phenomenological analysis (IPA). The inductive qualitative analysis data were transformed into numerical data. Interview extracts were coded as either forward-looking and hopeful (“mature”) or static and frustrated (“stuck”). Among males, significantly more mature outcomes were found among participants who had received MST compared with MAU. No differences were seen between the female groups. A detailed qualitative commentary shows how the constructs, mature and stuck, are manifest across the four domains. The findings suggest that working with an MST therapist during adolescence helped young men cultivate more mature, forward-looking viewpoints and life activities 4 years later when transitioning into adulthood. Findings are discussed in relation to relevant theory and practical applications.

Patterns and Predictors of Different Youth Responses to Attachment-Based Parent Intervention

Objective: Few studies have evaluated attachment-based parent interventions for pre-teens and teens, and in particular, differential adolescent trajectories of response. This study examined distinct patterns, and multi-level predictors, of intervention response among youth with serious behavioral and mental health problems whose parents participated in Connect, an attachment- and trauma-informed parent program.Method: Participants included 682 parents (M_age = 42.83, 86% mothers) and 487 youth (M_age = 13.95, 53% female, 28.1% ethnic minority) enrolled in a community-based evaluation of Connect. Parents and youth reported on youth externalizing and internalizing problems (EXT and INT) at six time points from baseline through 18-months post-intervention. Demographic and youth and family level predictors were assessed at baseline.Results: Growth mixture modeling revealed three distinct trajectory classes in both the parent and youth models based on different patterns of co-occurring EXT and INT and degree of improvement over time. Youth with severe EXT showed the largest and fastest improvement, and, interestingly, were characterized by higher callous-unemotional traits and risk-taking at program entry. Youth with comorbid EXT/INT demonstrated a partial or moderate response to intervention in the parent and youth model, respectively, and were characterized by more attachment anxiety at baseline. Most youth showed relatively moderate/low levels of EXT/INT at baseline which gradually improved. Caregiver strain also predicted trajectory classes.Conclusions: These results have significance for tailoring and personalizing interventions for high-risk youth and provide new understanding regarding the profiles of subgroups of youth who show different responses to an attachment-based parent intervention.

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.

Personality Pathology Profiles as Moderators of the Growing Pro-Social Program: Outcomes on Cognitive, Emotion, and Behavior Regulation in Male Prison Inmates

This study consisted of secondary data analysis of information collected from inmates who had participated in an earlier independent randomized controlled trial testing the effects of the Growing Pro-Social (GPS) program. The current study assessed personality disorders as moderators of the GPS effects in cognitive malfunctioning, emotion regulation strategies, and prison misconduct in male prison inmates. Participants were 254 inmates randomly assigned to either the GPS (n = 121) or the control group (n = 133). Participants completed self-report measures at four time points, and were interviewed with the SCID-II at baseline. Prison misconduct information was collected from prison records. Latent profile analysis identified four different personality pathology profiles. Mixed ANOVAs showed non-significant time × condition × personality pathology profiles effects, indicating that change on the outcome measures was not affected by personality pathology. Findings suggested that severely disturbed inmates could benefit from the GPS program, which stresses the need to provide appropriate treatment to offenders.

Epistemic Trust and the Emergence of Conduct Problems: Aggression in the Service of Communication

Fonagy and colleagues have recently proposed that deficits in the capacity for epistemic trust (i. e., the expectation that interpersonal communication is relevant to the addressee) are fundamental to psychopathology. In this paper, we consider the implications of this hypothesis for understanding the role of aggression in conduct disorder and conduct problems more generally. Our main proposal is to view conduct problems not only as reflecting dysregulation, but as an adaptation that allows communication with others who are (or are perceived to be) unreliable. Our formulation hinges on two propositions. The first one is to view aggression as a modality of communication adapted to scenarios in which the communicator expects the audience to have low epistemic trust in the communicator. The second idea is to conceptualize the failed "unlearning of aggression" as reflecting a lack of interest in maintaining one's reputation as a communicator, which in turn stems from a lack of epistemic trust in other communicators. In this paper, we discuss these ideas and examine how they may account for the developmental pathways that lead young people to develop conduct problems.

A Systematic Review of Primary and Secondary Callous-Unemotional Traits and Psychopathy Variants in Youth

Two variants of callous-unemotional (CU) traits and psychopathy have been proposed, referred to as primary and secondary. Whereas primary variants are thought to be underpinned by insufficient arousal to emotional cues, secondary variants are thought to develop as a coping mechanism in response to trauma exposure. Compared with adult samples, research on primary and secondary variants in children and adolescents under the age of 18 has only emerged in the past decade, and there is ongoing debate with regards to the identification, defining characteristics, and distinct correlates of these variants. The present systematic review synthesizes the current literature on primary and secondary variants in relation to: (1) constructs used to distinguish and define primary and secondary variants; (2) study population characteristics; (3) data analytic techniques to differentiate variants; and (4) differential associations with theoretically relevant indices related to emotional processing, maltreatment, biomarkers, and behavioral outcomes (e.g., substance use, aggression). This is the first systematic review to examine the growing literature on primary and secondary CU and psychopathy variants among youth. Findings support the distinction between youth with primary versus secondary variants and demonstrate that this distinction is related to unique clinical correlates. Recommendations are made for future research in the field.

Implementation of a Behavioral Intervention in a Juvenile Detention Center: Do Individual Characteristics Matter?

A sample of 129 (73% male) youth admitted consecutively into a juvenile detention center were used to examine individual characteristics that contribute the implementation of a behavioral intervention within a juvenile detention center. Given that a system of rewards and punishments is considered the mechanism of change within many behavioral interventions, individuals risk characteristics (i.e., proactive and reactive aggression, behavioral inhibition, subsystems of behavioral activation, callous-unemotional traits, perceived containment) were examined in relation to the rewards (i.e., positive feedback) and punishments (i.e., fines) used by the facility. Data were collected via structured interviews with youth and archival data. The number of days youth spent in detention was the only predictor of positive feedback received. Number of days in detention, sex, and race were related to fines. Behavioral activation drive was the only individual characteristic related to fines. Implications of findings 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.

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.

Heterogeneity in Response during Multisystemic Therapy: Exploring Subgroups and Predictors

Multiple studies have shown that Multisystemic Therapy (MST) is, at group level, an effective treatment for adolescents showing serious externalizing problem behavior. The current study expands previous research on MST by, first, examining whether subgroups of participants who respond differently to treatment could be identified. Second, we investigated if the different trajectories of change during MST could be predicted by individual (hostile attributions) and contextual (parental sense of parenting competence and deviant and prosocial peer involvement) pre-treatment factors. Participants were 147 adolescents (mean age = 15.91 years, 104 (71%) boys) and their parents who received MST. Pre-treatment assessment of the predictors and 5 monthly assessments of externalizing behavior during treatment took place using both adolescent and parents’ self-reports. Six distinct subgroups, showing different trajectories of change in externalizing problem behavior during MST, were identified. Two of the 6 trajectories of change showed a poor treatment response, as one class did not change in externalizing problem behavior and the other class even increased. The remaining 4 trajectories displayed a positive effect of MST, by showing a decrease in externalizing behavior. Most of these trajectories could be predicted by parental sense of parenting competence. Additionally, lower involvement with prosocial peers was a predictor of the group that appeared to be resistant to MST. Adolescents do respond differently to MST, which indicates the importance of personalizing treatment. Protective factors, such as parental sense of parenting competence and prosocial peers, seem to require additional attention in the first phase of MST.

Do Extremely Violent Juveniles Respond Differently to Treatment?

This study increases knowledge on effectiveness of treatment for extremely violent (EV) youth by investigating their response to multisystemic therapy (MST). Using data of a randomized controlled trial on effectiveness of MST, we investigated differences in treatment response between EV youth and not extremely violent (NEV) youth. Pre- to post-treatment comparison indicated MST was equally effective for EV and NEV youth, whereas treatment as usual was not effective for either group. Growth curves of within-treatment changes indicated EV youth responded differently to MST than NEV youth. The within-treatment change was for EV youth non-linear: Initially, they show a deterioration; however, after one month, EV juveniles respond positively to MST, indicating longer lasting, intensive programs may be effective in treating extreme violence.

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 problems in youth and the RDoC approach: A developmental, evolutionary-based view

Problems related to aggression in young people are traditionally subsumed under the header of conduct problems, which include conduct disorder and oppositional defiant disorder. Such problems in children and adolescents are an important societal and mental health problem. In this paper we present an evolutionarily informed developmental psychopathology view of conduct problems inspired by the NIMH Research Domain Criteria (RDoC) initiative. We assume that while there are many pathways to conduct problems, chronic or temporary impairments in the domain of social cognition or mentalizing are a common denominator. Specifically, we conceptualize conduct problems as reflecting temporary or chronic difficulties with mentalizing, that is, the capacity to understand the self and others in terms of intentional mental states, leading to a failure to inhibit interpersonal violence through a process of perspective-taking and empathy. These difficulties, in turn, stem from impairments in making use of a normally evolutionarily protected social learning system that functions to facilitate intergenerational knowledge transmission and protect social collaborative processes from impulsive and aggressive action. Temperamental, biological, and social risk factors in different combinations may all contribute to this outcome. This adaptation then interacts with impairments in other domains of functioning, such as in negative and positive valence systems and cognitive systems. This view highlights the importance of a complex interplay among biological, psychological, and environmental factors in understanding the origins of conduct problems. We outline the implications of these views for future research and intervention.

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.

Treating conduct disorder: An effectiveness and natural language analysis study of a new family-centred intervention program

This paper reports on a new family-centred, feedback-informed intervention focused on evaluating therapeutic outcomes and language changes across treatment for conduct disorder (CD). The study included 26 youth and families from a larger randomised, controlled trial (Ronan et al., in preparation). Outcome measures reflected family functioning/youth compliance, delinquency, and family goal attainment. First- and last-treatment session audio files were transcribed into more than 286,000 words and evaluated through the Linguistic Inquiry and Word Count Analysis program (Pennebaker et al., 2007). Significant outcomes across family functioning/youth compliance, delinquency, goal attainment and word usage reflected moderate-strong effect sizes. Benchmarking findings also revealed reduced time of treatment delivery compared to a gold standard approach. Linguistic analysis revealed specific language changes across treatment. For caregivers, increased first person, action-oriented, present tense, and assent type words and decreased sadness words were found; for youth, significant reduction in use of leisure words. This study is the first using lexical analyses of natural language to assess change across treatment for conduct disordered youth and families. Such findings provided strong support for program tenets; others, more speculative support.

Child and case influences on recidivism in a statewide dissemination of Multisystemic Therapy for juvenile offenders

Multisystemic Therapy (MST) is an evidence-based treatment for high-risk youth and their families shown to reduce subsequent delinquent activity. This study investigated (1) re-arrest rates of a statewide MST dissemination; and (2) the relation of child, family, and case characteristics to re-arrest rates following receipt of MST. Analyses examined outcomes for 633 youth following referral to MST. Separate models examined predictors of general re-arrest of any type and of more serious misdemeanor or felony arrests. Sixty-five percent of youth experienced a new arrest of any type within 12-months of MST initiation; fewer (53%) experienced a misdemeanor or felony charge in that timeframe. Recipients who were younger, had an externalizing behavior disorder, and had a greater number and severity of pre-MST charges were more likely to recidivate. Findings highlight potential child and case factors that may account for variability in treatment effects when MST is implemented broadly within a system.

Psychiatric evaluation of youths with Disruptive Behavior Disorders and psychopathic traits: A critical review of assessment measures

Disruptive Behavior Disorders (DBDs) are stable and impairing disorders, heterogeneous in presentation, developmental pathways, and treatment needs. Disentangling subtypes according to psychopathological dimensions is helpful for timely diagnoses, precise prognoses and tailored interventions. Psychopathic traits are relevant in subtyping DBDs with severe antisocial and aggressive behaviors. Three psychopathy dimensions have been found: 1) an affective dimension, the callous-unemotional (CU) trait, with lack of empathy and remorse, and with short-lived emotions; 2) an interpersonal dimension, the narcissistic domain, with manipulative abilities, superficial charm, egocentricity and grandiosity; 3) a behavioral dimension, the impulsivity or impulsive-irresponsibility, with irresponsibility, proneness to boredom, and novelty seeking. Recently, research suggests that youth with CU traits, similarly to adults with psychopathy, can present a low-anxious "primary" and high-anxious "secondary" variants. Our aim is to critically review the main measures of psychopathic traits, including the three main dimensions (with specific emphasis on CU traits), and the "primary/secondary" distinction, focusing on the assessment in clinical settings. An assessment procedure is proposed, based on previous literature and personal clinical experience.

Multisystemic Therapy(®) : Clinical Overview, Outcomes, and Implementation Research

Multisystemic therapy (MST) is an evidence-based treatment originally developed for youth with serious antisocial behavior who are at high risk for out-of-home placement and their families; and subsequently adapted to address other challenging clinical problems experience by youths and their families. The social-ecological theoretical framework of MST is presented as well as its home-based model of treatment delivery, defining clinical intervention strategies, and ongoing quality assurance/quality improvement system. With more than 100 peer-reviewed outcome and implementation journal articles published as of January 2016, the majority by independent investigators, MST is one of the most extensively evaluated family based treatments. Outcome research has yielded almost uniformly favorable results for youths and families, and implementation research has demonstrated the importance of treatment and program fidelity in achieving such outcomes.

[Does the Youth Psychopathic Traits Inventory (YPI) identify a clinically relevant subgroup among young offenders?]

Objective

Does the Youth Psychopathic Traits Inventory identify one or more high-risk subgroups among young offenders? Which recommendations for possible courses of action can be derived for individual clinical or forensic cases? Method: Model-based cluster analysis (Raftery, 1995) was conducted on a sample of young offenders (N = 445, age 14–22 years, M = 18.5, SD = 1.65). The resulting model was then tested for differences between clusters with relevant context variables of psychopathy. The variables included measures of intelligence, social competence, drug use, and antisocial behavior. Results: Three clusters were found (Low Trait, Impulsive/Irresponsible, Psychopathy) that differ highly significantly concerning YPI scores and the variables mentioned above. The YPI Scores Δ Low = 4.28 (Low Trait – Impulsive/Irresponsible) and Δ High = 6.86 (Impulsive/Irresponsible – Psychopathy) were determined to be thresholds between the clusters.

Conclusions

The allocation of a person to be assessed within the calculated clusters allows for an orientation of consequent tests beyond the diagnosis of psychopathy. We conclude that the YPI is a valuable instrument for the assessment of young offenders, as it yields clinically and forensically relevant information concerning the cause and expected development of psychopathological behavior.

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.

A Behavioral Measure of Costly Helping: Replicating and Extending the Association with Callous Unemotional Traits in Male Adolescents

BACKGROUND

Some conduct-disordered youths have high levels of callous unemotional traits and meet the DSM-5's "with limited prosocial emotions" (LPE) specifier. These youths often do aggressive, self-benefitting acts that cost others. We previously developed a task, the AlAn's game, which asks participants to repeatedly decide whether to accept or reject offers in which they will receive money but a planned charity donation will be reduced. In our prior work, more "costly helping" (i.e., rejecting the offered money and protecting the donation) was associated with lower callous unemotional traits. Here we extend that prior work in a larger sample of adolescent male patients with serious conduct problems and controls, and test whether this association is mediated specifically by a Moral Elevation response (i.e., a positive emotional response to another's act of virtue).

METHODS

The adolescent male participants were: 45 patients (23 with LPE) and 26 controls, who underwent an extensive phenotypic assessment including a measure of Moral Elevation. About 1 week later participants played the AlAn's game.

RESULTS

All AlAn's game outcomes demonstrated significant group effects: (1) money taken for self (p = 0.02); (2) money left in the charitable donation (p = 0.03); and, (3) costly helping (p = 0.047). Controls took the least money and did the most costly helping, while patients with LPE took the most money and did the least costly helping. Groups also significantly differed in post-stimulus Moral Elevation scores (p = 0.005). Exploratory analyses supported that the relationship between callous unemotional traits and costly helping on the AlAn's game may be mediated in part by differences in Moral Elevation.

CONCLUSIONS

The AlAn's game provides a standardized behavioral measure associated with callous unemotional traits. Adolescents with high levels of callous unemotional traits engage in fewer costly helping behaviors, and those differences may be related to blunting of positive emotional responses.

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.

Narcissism and Callous-Unemotional Traits Prospectively Predict Child Conduct Problems

Although narcissism and callous-unemotional (CU) traits are separable facets of psychopathy, their independent prediction of conduct problems (CP) among young children is not well known. In addition, above-average IQ was central to the original conceptualization of psychopathy, yet IQ is typically inversely associated with youth CP. We examined narcissism and CU traits as independent and prospective predictors of oppositional defiant disorder (ODD), conduct disorder (CD), and youth self-reported antisocial behavior, as well as their moderation by IQ. At baseline, parents and teachers separately rated narcissism and CU traits in 188 6-to-10-year-old children (47.9% non-White; 69.1% male; M = 7.34 years, SD = 1.09) with (n = 99) and without (n = 89) attention-deficit/hyperactivity disorder (ADHD). Approximately 2 years later, parents and teachers separately rated youth ODD and CD symptoms, and youth self-reported antisocial behavior. With control of baseline ADHD and ODD/CD symptoms, narcissism and CU traits independently and positively predicted ODD and CD symptoms at follow-up. IQ did not moderate any CP predictions from baseline narcissism or CU traits. These preliminary findings suggest that individual differences in narcissism and CU traits, even relatively early in development, are uniquely associated with emergent CP. Findings are considered within a developmental framework and the multiple pathways underlying the heterogeneity of CP are discussed.

Test of "Facilitation" vs. "Proximal Process" Moderator Models for the Effects of Multisystemic Therapy on Adolescents with Severe Conduct Problem

The present study identified moderators of Multisystemic Therapy's (MST) effects on adolescent conduct problems, considering facilitation and proximal process moderation models. The sample included 164 adolescents (mean age = 14.6 years; 83% male) randomly assigned to receive MST or services as usual; parent, youth, and teacher reports of adolescent functioning were obtained. A number of significant moderators were identified. Proximal process moderation patterns were identified (e.g., families with parents with lower levels of adaptive child discipline skills gained more from MST), but the majority of significant interactions showed a facilitation moderation pattern with, for instance, higher levels of adaptive functioning in families and parents appearing to facilitate MST (i.e., greater benefits from MST were found for these families). This facilitation pattern may reflect such families being more capable of and/or more motivated to use the resources provided by MST. It is suggested that factors consistently identified as facilitation moderators may serve as useful foci for MST's strength-based levers of change approach. Other implications of these findings for individualized treatment also are discussed.

Psychopathic traits from an RDoC perspective

In this review an RDoC approach is applied to psychopathic traits. Two core neuro-cognitive systems relevant to the emergence of psychopathic traits are considered. These are the response to other individuals' emotional displays and reinforcement-based decision-making.

Disruptive behaviour disorders and DSM-5

This article provides an overview of the revisions to the diagnoses of oppositional defiant disorder (ODD) and conduct disorder (CD) in DSM-5, and examines the key issues they raise. Particular attention is given to these changes in light of current treatment outcome evidence, including that published since the development of DSM-5. For both ODD and CD, DSM-5 retains the core features that previously defined the phenotypes for these diagnoses. DSM-5 nonetheless introduces a number of revisions pertaining to the guidelines for the application of these criteria, and markers for key individual differences in presentations of these disorders. These revisions reflect small but significant steps towards the perspective that children with disruptive behaviour problems are a highly heterogeneous population, and best characterised on the basis of both behavioural and emotional features. Importantly, there is growing evidence that the newly introduced changes to these diagnoses in DSM-5 may be better able to inform predictions regarding treatment response than previous diagnostic criteria.

Callous-unemotional traits in children and mechanisms of impaired eye contact during expressions of love: a treatment target?

BACKGROUND

We previously hypothesised that the early development of psychopathy is associated with a failure to attend to the eyes of attachment figures, and we have presented preliminary data from a parent-child 'love' scenario in support of this. Here, we confirm the association in a larger sample and test mechanisms of impaired eye contact during expressions of love in control and behaviourally disturbed children.

METHODS

Oppositional defiant disorder children, assessed for callous-unemotional (CU) traits, and controls, were observed in a brief interaction task where the mother was asked to show love to her child. Eye contact and affection were measured for each dyad.

RESULTS

As predicted, there were no group differences in affection and eye contact expressed by mothers; levels of CU traits predicted low levels of eye contact towards their mothers across all groups of children. As expected, low eye contact was correlated with psychopathic fearlessness in their fathers, and maternal reports of negative feelings towards the child. Independent observations showed that child's behaviour largely drives the low eye contact associated with CU traits, and low eye contact was not associated with independent observations of the quality of attachment-related behaviours in mothers.

CONCLUSIONS

Impaired eye contact is a unique characteristic of children with CU traits; these impairments are largely independent of maternal behaviour, but associated with psychopathic traits in the fathers. These impairments should be tested for functional significance and amenability to change in longitudinal and treatment studies.

The neurobiology of psychopathic traits in youths

Conduct disorder is a childhood behaviour disorder that is characterized by persistent aggressive or antisocial behaviour that disrupts the child's environment and impairs his or her functioning. A proportion of children with conduct disorder have psychopathic traits. Psychopathic traits consist of a callous-unemotional component and an impulsive-antisocial component, which are associated with two core impairments. The first is a reduced empathic response to the distress of other individuals, which primarily reflects reduced amygdala responsiveness to distress cues; the second is deficits in decision making and in reinforcement learning, which reflects dysfunction in the ventromedial prefrontal cortex and striatum. Genetic and prenatal factors contribute to the abnormal development of these neural systems, and social-environmental variables that affect motivation influence the probability that antisocial behaviour will be subsequently displayed.