Facial Affect Sensitivity Training for Young Children with Emerging CU Traits: An Experimental Therapeutics Approach

Deficits in emotion recognition and processing in children with high callous-unemotional traits: the role of the MAOA gene

Children with high Callous-Unemotional (CU) traits show deficits in recognizing and processing facial expressions. Alterations in emotion recognition have been linked to a higher synaptic concentration of monoaminergic neurotransmitters. The current study investigated the relationship between the MAOA-Low-activity alleles and the ability to recognize and process facial expressions in 97 male children (8-12 years old) diagnosed with disruptive behavior disorder. Participants completed a computerized emotion-recognition task while an eye-tracking system recorded the number (Fixation Count, FC) and length (Fixation Duration, FD) of fixations to the eye region of the emotional stimuli. Children with high CU traits exhibited lower scores in recognition of sadness and anger, and lower FC and FD for sadness and fear than children with low CU traits. Children carrying the MAOA-Low-activity alleles displayed lower FD for sadness, and FD and FC for fear than those carrying the MAOA-High-activity alleles. These genetic effects appeared even stronger in children with CU traits. Moderation analysis revealed that CU traits were associated with lower FC and FD for fear, and lower FD for sadness, probably due to the MAOA-Low-activity alleles. Our findings, although to be replicated, suggest MAOA-Low-activity alleles as potential genetic biomarkers to identify CU children in need of training focused on emotion processing.

The Emotionally Sensitive Child-Adverse Parenting Experiences-Allostatic (Over)Load (ESCAPE-AL) Model for the Development of Secondary Psychopathic Traits

Understanding and treatment of antisocial behavior have improved through efforts to subtype individuals based on similar risk factors and outcomes. In particular, the presence of psychopathic traits is associated with distinct etiological factors and antisocial behavior that begins early in life, is aggressive, persistent, and less likely to normalize with traditional treatments, relative to individuals low on psychopathy or its childhood precursor, callous-unemotional (CU) traits. However, important distinctions can be made within individuals with CU/psychopathic traits according to the presence of elevated anxiety symptoms and/or adverse childhood experiences, known as secondary psychopathy/CU traits. This paper provides a broad and brief overview of theory and empirical literature supporting the existence of secondary psychopathy/CU variants as a distinct subtype of childhood antisocial behavior. It outlines the Emotionally Sensitive Child-Adverse Parenting Experiences-Allostatic (Over)Load (ESCAPE-AL) model for the developmental psychopathology of secondary psychopathic/CU traits and discusses research and theory supporting this perspective. Future research directions for testing this conceptual model and its implications for assessing and treating high-risk individuals with secondary CU/psychopathic traits are discussed.

Treatment Outcomes of Children with Primary Versus Secondary Callous-Unemotional Traits

OBJECTIVE

Recent efforts to improve outcomes for young children with conduct problems and callous-unemotional (CU) traits involve adapting treatments to meet the unique needs of this subgroup. However, these efforts have ignored accumulating evidence for distinct primary and secondary variants within the CU subgroup. Existing treatment adaptations uniformly target risk factors associated with primary CU traits and no studies have investigated variant-specific patterns of responsiveness to treatment adaptations among young children with CU-type conduct problems.

METHOD

Participants were 45 families with a 3- to 7-year-old clinic-referred child (M = 4.84 years, SD = 1.08, 84% boys) with conduct problems and CU traits. Primary and secondary CU variants were defined based on baseline parent-rated anxiety scores. All families received Parent-Child Interaction Therapy adapted for CU traits (PCIT-CU) at an urban university-based research clinic. Families completed five assessments measuring child conduct problems and affective outcomes.

RESULTS

Linear mixed-effects modeling showed that the rate and shape of change over time in conduct problems differed between variants, such that children with secondary CU traits showed deterioration in defiant and dysregulated behaviors from post-treatment to follow-up, whereas primary CU traits were associated with maintained gains. There were no variant differences in rate of improvement in CU traits. Affective empathy did not improve for either variant. Internalizing problems meaningfully improved by follow-up for children with secondary CU traits.

CONCLUSIONS

Findings suggest that PCIT-CU is a promising intervention for children with conduct problems and primary CU traits, but may require further personalization for children with secondary CU traits. This trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616000280404).

Executive function and underlying brain network distinctions for callous-unemotional traits and conduct problems in adolescents

The complexity of executive function (EF) impairments in youth antisocial phenotypes of callous-unemotional (CU) traits and conduct problems (CP) challenge identifying phenotypic specific EF deficits. We can redress these challenges by (1) accounting for EF measurement error and (2) testing distinct functional brain properties accounting for differences in EF. Thus, we employed a latent modeling approach for EFs (inhibition, shifting, fluency, common EF) and extracted connection density from matching contemporary EF brain models with a sample of 112 adolescents (ages 13-17, 42% female). Path analysis indicated CU traits associated with lower inhibition. Inhibition network density positively associated with inhibition, but this association was strengthened by CU and attenuated by CP. Common EF associated with three-way interactions between density*CP by CU for the inhibition and shifting networks. This suggests those higher in CU require their brain to work harder for lower inhibition, whereas those higher in CP have difficulty engaging inhibitory brain responses. Additionally, those with CP interacting with CU show distinct brain patterns for a more general EF capacity. Importantly, modeling cross-network connection density in contemporary EF models to test EF involvement in core impairments in CU and CP may accelerate our understanding of EF in these phenotypes.

Efficiency of Heterogenous Functional Connectomes Explains Variance in Callous-Unemotional Traits After Computational Lesioning of Cortical Midline and Salience Regions

Introduction: Callous-unemotional (CU) traits are a youth antisocial phenotype hypothesized to be a result of differences in the integration of multiple brain systems. However, mechanistic insights into these brain systems are a continued challenge. Where prior work describes activation and connectivity, new mechanistic insights into the brain's functional connectome can be derived by removing nodes and quantifying changes in network properties (hereafter referred to as computational lesioning) to characterize connectome resilience and vulnerability. Methods: Here, we study the resilience of connectome integration in CU traits by estimating changes in efficiency after computationally lesioning individual-level connectomes. From resting-state data of 86 participants (48% female, age 14.52 ± 1.31) drawn from the Nathan Kline institute's Rockland study, individual-level connectomes were estimated using graphical lasso. Computational lesioning was conducted both sequentially and by targeting global and local hubs. Elastic net regression was applied to determine how these changes explained variance in CU traits. Follow-up analyses characterized modeled node hubs, examined moderation, determined impact of targeting, and decoded the brain mask by comparing regions to meta-analytic maps. Results: Elastic net regression revealed that computational lesioning of 23 nodes, network modularity, and Tanner stage explained variance in CU traits. Hub assignment of selected hubs differed at higher CU traits. No evidence for moderation between simulated lesioning and CU traits was found. Targeting global hubs increased efficiency and targeting local hubs had no effect at higher CU traits. Identified brain mask meta-analytically associated with more emotion and cognitive terms. Although reliable patterns were found across participants, adolescent brains were heterogeneous even for those with a similar CU traits score. Conclusion: Adolescent brain response to simulated lesioning revealed a pattern of connectome resiliency and vulnerability that explains variance in CU traits, which can aid prediction of youth at greater risk for higher CU traits.

Contemporary diagnosis and treatment of conduct disorder in youth

INTRODUCTION

Conduct disorder (CD) is characterized by repetitive and persistent antisocial behaviors, being among the most frequently reported reasons of referral in youth. CD is a highly heterogeneous disorder, with possible specifiers defined according to age at onset, Limited Prosocial Emotions (LPE) otherwise known as Callous-Unemotional (CU) traits, Emotional Dysregulation (ED), and patterns of comorbidity, each with its own specific developmental trajectories.

AREAS COVERED

The authors review the evidence from published literature on the clinical presentations, diagnostic procedures, psychotherapeutic and psychoeducational approaches, and pharmacological interventions from RCT and naturalistic studies in youth. Evidence from studies including youths with LPE/CU traits, ED and aggression are also reviewed, as response moderators.

EXPERT OPINION

Due to its clinical heterogeneity, relevant subtypes of CD should be carefully characterized to gain reliable information on prognosis and treatments. Thus, disentangling this broad category in subtypes is crucial as a first step in diagnosis. Psychosocial interventions are the first option, possibly improving LPE/CU traits and ED, especially if implemented early during development. Instead, limited information, based on low-quality studies, supports pharmacological options. Second-generation antipsychotics, mood stabilizers, and stimulants are first-line medications, according to different target symptoms, such as aggression and emotional reactivity. Developmental pathways including ADHD suggest a specific role of psychostimulants.

Cognitive Mechanisms Underlying Prosocial Decision Making in Callous-Unemotional Traits

Callous-unemotional (CU) traits are characterized by a lack of prosocial emotions, which has been demonstrated with prosocial behavior paradigms. While shaping our understanding of prosocial behavior in youth with CU traits, most of this work relies on outcomes that don't reliably capture cognitive processes during prosocial behavior. Examining prosocial cognitive processes can cue researchers into cognitive mechanisms underlying core impairments of CU traits. Drift diffusion modeling is a valuable tool for elucidating more precise outcomes of latent cognitive processes during forced choice tasks such as drift rate (information accumulation toward a decision boundary) and threshold separation (amount of information considered) as well as metrics outside of the decision-making processing including bias (starting point in decision process) and non-decision time (cognitive processes outside of choice). In a sample of 87 adolescents (12-14, 49% female) we applied diffusion modeling to a prosocial behavior task in which participants either accepted or rejected trials where a real monetary value was given to them and taken away from a charity (self-serving trial) or money was given to a charity and taken from them (donation trial). Results revealed that CU traits associated with information accumulation toward accepting self-serving trials. Exploratory sex differences suggested males trended toward rejecting donation trials and females considered more information during self-serving trials. CU trait associations were independent of conduct problems. Results suggest a unique cognitive profile that are differentiated by sex at higher CU traits when making prosocial decisions involving knowledge accumulation toward self-serving decisions.

Affective theory of mind impairments underlying callous-unemotional traits and the role of cognitive control

Affective theory of mind (aToM) impairments associated with the youth antisocial phenotype callous-unemotional (CU) traits predict antisocial behaviour above CU traits alone. Importantly, CU traits associate with decrements in complex but not basic aToM. aToM is modulated by cognitive control and CU traits associate with cognitive control impairments; thus, cognitive control is a plausible mechanism underlying aToM impairments in CU traits. Because cognitive control is dependent on the availability of cognitive resources, youth with CU traits may have difficulty with allocating cognitive resources under greater demands that impact complex aToM. To test this, 81 participants (ages 12-14, Female = 51.8%, Male = 48.2%) were recruited to complete a behavioural paradigm that involved an initial aToM task with complex and basic emotions followed by placing additional demands on cognitive control and a final repeat of the same aToM task. Results indicate adolescents higher in CU traits had intact basic aToM but less accuracy in complex aToM that worsened after taxing cognitive control; and this load only required a short duration to account for ToM decrements (200 ms [range 150-1600 ms]). These results demonstrate CU traits association with cognitive control limitations that impact complex aToM. This may partially explain antisocial behaviour associated with CU traits.