Predictors of nonresponse to psychosocial treatment in children and adolescents with disruptive behavior disorders

Childhood maltreatment affects adolescent sensitivity to parenting and close friendships in predicting growth in externalizing behavior

Childhood maltreatment robustly predicts adolescent externalizing behaviors (EB; e.g., violence, delinquency, substance use) and may crystalize patterns of EB by influencing sensitivity to the social environment (e.g., parenting, friendships). In a nationally representative sample of 9,421 adolescents, we modeled latent growth curves of EB from age 13 to 32 years. Next, we explored whether maltreated youth differed from nonmaltreated youth in their sensitivity to parental closeness, friendship involvement, and polymorphisms from dopamine genes linked to EB (dopamine receptors D2 and D4, dopamine transporter). Overall, maltreated youth had significantly higher levels of EB across adolescence and adulthood; however, maltreated and nonmaltreated youth showed similar patterns of EB change over time: violent behavior decreased in adolescence before stabilizing in adulthood, whereas nonviolent delinquency and substance use increased in adolescence before decreasing in the transition to adulthood. Maltreatment reduced sensitivity to parental closeness and friendship involvement, although patterns varied based on type of EB outcome. Finally, none of the environmental effects on EB were significantly moderated by the dopamine polygenic risk score after accounting for multiple testing. These findings underline the enduring effects of early maltreatment and implicate that maltreatment may contribute to long-term risk for EB by influencing children's sensitivity to social relationship factors in adolescence.

Why is this Happening? A Brief Measure of Parental Attributions Assessing Parents' Intentionality, Permanence, and Dispositional Attributions of Their Child with Conduct Problems

We present and evaluate a new self-report measure of parental attributions developed for assessing child causal and dispositional attributions in parenting interventions. The Parent Attribution Measure (PAM) ascribes attributions along first-order dimensions of intentionality, permanence, likeability, and disposition, and a higher-order Total Scale. The psychometric analyses involved participants drawn from populations of clinical (n = 318) and community-based families (n = 214) who completed questionnaires assessing parental attributions, parenting behaviours, parental depression, parental feelings about the child, and child behavioural problems. Confirmatory factor analysis indicated that a 3-factor hierarchical structure provided a close fitting model. The model with intentionality, permanence, and disposition (consolidating likeability and disposition) dimensions as first-order factors grouped under a higher-order general factor was validated in independent samples and demonstrated sound psychometric properties. The PAM presents as a brief measure of parental attributions assessing parents' intentionality, permanence, and dispositional attributions of their child with conduct problems.

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.

Temperamental sensitivity to early maltreatment and later family cohesion for externalizing behaviors in youth adopted from foster care

Children in foster care frequently have histories of physical/sexual abuse and neglect, increasing their risk for externalizing behaviors (EB; e.g., aggression). According to the differential susceptibility theory, children with reactive temperaments (e.g., negative emotionality) may be particularly vulnerable to early maltreatment, but may also benefit the most from environmental enrichment such as family cohesion. In a high-risk longitudinal sample of 82 children adopted from foster care in Los Angeles County from 1996 and 2001, we examined predictions of EB from childhood to adolescence/young adulthood from temperament, preadoption maltreatment, and adoptive family cohesion. Overall, results from generalized linear models and generalized estimating equations (GEE) did not support differential susceptibility theory - specifically, youth with early reactive temperament did not exhibit heightened sensitivity to maltreatment nor to later adoptive family cohesion. Instead, reactive temperament was associated with higher EB at initial adoptive placement and escalating EB across childhood, controlling for age, gender, race-ethnicity, preadoption maltreatment, and adoptive family cohesion. Preadoption maltreatment history was unrelated to baseline EB, although sexual abuse history predicted escalating childhood EB post-adoption, whereas exposure to family violence (e.g., domestic violence) inversely predicted EB over time. By late adolescence/young adulthood 11-15 years post-adoption, rates of arrest and substance use in this sample were relatively comparable to normative populations of youth, although older age of adoption predicted more substance use in late adolescence/young adulthood. Findings highlight early reactive temperament and preadoption maltreatment as important risk factors to target for ameliorating patterns of EB growth in the first few years of adoption.

Multidimensional Predictors of Treatment Outcome in Usual Care for Adolescent Conduct Problems and Substance Use

This study investigated baseline client characteristics that predicted long-term treatment outcomes among adolescents referred from school and community sources and enrolled in usual care for conduct and substance use problems. Predictor effects for multiple demographic (age, sex, race/ethnicity), clinical (baseline symptom severity, comorbidity, family discord), and developmental psychopathology (behavioral dysregulation, depression, peer delinquency) characteristics were examined. Participants were 205 adolescents (52 % male; mean age 15.7 years) from diverse backgrounds (59 % Hispanic American, 21 % African American, 15 % multiracial, 6 % other) residing in a large inner-city area. As expected, characteristics from all three predictor categories were related to various aspects of change in externalizing problems, delinquent acts, and substance use at one-year follow-up. The strongest predictive effect was found for baseline symptom severity: Youth with greater severity showed greater clinical gains. Higher levels of co-occurring developmental psychopathology characteristics likewise predicted better outcomes. Exploratory analyses showed that change over time in developmental psychopathology characteristics (peer delinquency, depression) was related to change in delinquent acts and substance use. Implications for serving multiproblem adolescents and tailoring treatment plans in routine care are discussed.

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.

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.

Combined pharmacotherapy-multimodal psychotherapy in children with Disruptive Behavior Disorders

Although multi-component psychotherapeutic interventions are first-line treatments for Disruptive Behavior Disorders (DBD), pharmacotherapy is often associated for more severe patients. Our aim was to explore effectiveness of an associated pharmacotherapy in referred children with DBD receiving a one-year psychotherapeutic intervention. Aggression, callous unemotional (CU) traits and emotional dysregulation were outcome measures. The sample included 144 children, aged 8-12 years, 41 (29%) with an ADHD comorbidity. Fifty-five (38%) patients received an additional pharmacotherapy with one medication, methylphenidate, a second generation antipsychotic, or a mood stabilizer. Data were collected before and after the one-year treatment. According to the Child Behavior Checklist (CBCL), aggressive behaviors, rule-breaking behaviors and emotional dysregulation improved in the whole group, as well as parent- and child-reported CU traits. The hierarchical regression model showed that additional pharmacotherapy significantly predicted lower scores at the CBCL aggressive behaviors and emotional dysregulation, but not CU traits at the end of the treatment. The interaction between methylphenidate and ADHD comorbidity predicted lower aggressive behaviors after the treatment. In summary, this naturalistic investigation suggest that an additional pharmacotherapy significantly improved aggression and emotional dysregulation, but not CU traits. When ADHD was comorbid, methylphenidate was more effective than antipsychotics or mood stabilizers in reducing aggression.

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.

Clinical Profiles of Children with Disruptive Behaviors Based on the Severity of Their Conduct Problems, Callous-Unemotional Traits and Emotional Difficulties

This study identified clinical profiles of referred children based on the severity of callous-unemotional (CU) traits, emotional difficulties, and conduct problems. Parents of 166 children (132 males) aged 6-12 years referred to a hospital clinic because of disruptive behavior completed measures to assess these key indicators, and person-centered analysis was used to identify profiles. Four distinct profiles were identified that include: (1) Children low in severity on the three domains, (2) Children high in severity on the three domains, (3) Children high in severity in conduct problems and CU traits with minimal emotional difficulties, and (4) Children high in severity in conduct problems and emotional difficulties with minimal CU traits. Profiles differed in degree of aggression and behavioral impairment. Findings show that clinic-referred children with disruptive behaviors can be grouped based on these important indicators into profiles that have important implications for assessment and treatment selection.

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.

Emotional reactivity in referred youth with disruptive behavior disorders: the role of the callous-unemotional traits

Deficits in emotional reactivity are frequently reported in Disruptive Behavior Disorders (DBDs). A deficit in prosocial emotions, namely the callous unemotional traits (CU), may be a mediator of emotional reactivity. Our aim is to investigate subjective emotional reactivity towards visual stimuli with different affective valence in youths with DBDs and healthy controls. The clinical sample included 62 youths with DBDs (51 males, 8 to 16 years, mean 11.3±2.1 years), the control group 53 subjects (36 males, 8 to 16 years, mean 10.8±1.5 years). The groups were compared using the Child Behavior Checklist (CBCL), the Inventory of Callous-Unemotional Traits (ICU), and the International Affective Picture System (IAPS), which explores the affective (pleasant/unpleasant emotional reaction) and arousal (low/high intensity of emotion) dimensions. The DBD group presented higher scores in externalizing and internalizing CBCL scores, and in ICU callous and indifferent subscales. At the IAPS, DBD patients differed from controls in the affective valence of the images, rating less unpleasant neutral and negative images. The CU traits were the only predictor of emotional reactivity in the DBD sample. A less aversive way to interpret neutral and negative stimuli may explain why DBD patients are less responsive to negative reinforcements.

Behavior therapy and callous-unemotional traits: effects of a pilot study examining modified behavioral contingencies on child behavior

The conduct problems of children with callous-unemotional (CU) traits (i.e., lack of empathy, lack of guilt/lack of caring behaviors) are particularly resistant to current behavioral interventions, and it is possible that differential sensitivities to punishment and reward may underlie this resistance. Children with conduct problems and CU (CPCU) are less responsive to behavioral punishment techniques (e.g., time-out), whereas reward techniques (e.g., earning points for prizes or activities) are effective for reducing conduct problems. This study examined the efficacy of modified behavioral interventions, which de-emphasized punishment (Condition B) and emphasized reward techniques (Condition C), compared with a standard behavioral intervention (Condition A). Interventions were delivered through a summer treatment program over 7 weeks with an A-B-A-C-A-BC-A design to a group of 11 children (7-11 years; 91% male). All children were diagnosed with either oppositional defiant disorder or conduct disorder, in addition to attention-deficit hyperactivity disorder. Results revealed the best treatment response occurred during the low-punishment condition, with rates of negative behavior (e.g., aggression, teasing, stealing) increasing over the 7 weeks. However, there was substantial individual variability in treatment response, and several children demonstrated improvement during the modified intervention conditions. Future research is necessary to disentangle treatment effects from order effects, and implications of group treatment of CPCU children (i.e., deviancy training) are discussed.

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.

Response to treatments in youth with disruptive behavior disorders

OBJECTIVE

Predictors of poor response to treatments in youths with disruptive behavior disorders (DBDs), including conduct disorder (CD) and oppositional defiant disorder (ODD), are under-studied. Multimodal psychosocial interventions are the best option, but a significant portion of patients needs adjunctive pharmacotherapy. The concept of "psychopathy", and namely, the callous (lack of empathy and guilt) and unemotional (shallow emotions) trait, has been considered a possible specifier indicating a more severe subgroup of patients. We explored whether the callous-unemotional trait (CU) may affect the response to multimodal treatment in referred youths with DBDs.

METHOD

118 youths (102 males, age range 6-14years, mean age 11.1±2.5years) completed a 12-month multimodal intervention, 48 of whom (41%) needed an associated pharmacotherapy. The patients were assessed according to psychopathological profile (Child Behavior Checklist, CBCL), severity and improvement (Clinical Global Impression-Severity and Improvement scores, CGI-S and CGI-I), functional impairment (Children-Global Assessment Scale, C-GAS), and psychopathic dimension (Antisocial Process Screening Device, APSD), including CU dimension.

RESULTS

58 patients (49.2%) were non-responders. They had more frequently a diagnosis of CD than ODD, presented a comorbid mood disorder, higher CBCL scores in rule-breaking behavior, and higher APSD ("psychopathic") scores. Subjects with higher or lower CU differed only according to the rate of responders (35% vs. 60%, p<.05). The linear blockwise regression indicated that pre-treatment functional impairment (C-GAS) and baseline CU trait were predictors of non-response. The logistic regression indicated that only the value of baseline APSD-CU trait was a predictor of non-response.

CONCLUSIONS

A careful assessment of baseline clinical functioning and psychopathological features, namely the psychopathic traits, can identify the most problematic patients, and has specific prognostic and treatment implications.

Interpersonal reactivity index: analysis of invariance and gender differences in spanish youths

Empathy is understood as a multidimensional construct involving both cognitive and emotional factors for which, traditionally, gender differences have been reported. The Interpersonal Reactivity Index (Davis in Catalog Sel Documents Psychol 10:1-19, 1980) is an instrument made up of four subscales, each measuring a different dimension of the global concept of empathy. Attending to gender differences, the present study's objective is twofold. First, it aims to determine, conceptually speaking, whether or not the model analyzed by this instrument is equivalent for the two sexes. Second, it aims to determine which dimensions involved in empathy most strongly predict gender differences. The results convey that the proposed model is invariant between boys and girls, although the dimensions exhibited significant differences of magnitude as a function of sex. Mainly two variables (Considerate Social Style and Impassiveness) were capable of distinguishing between men and women. Possible reasons for these results are also discussed.

Callous-unemotional traits as a cross-disorders construct

PURPOSE

Callous-unemotional (CU) traits are currently viewed as the defining signs and symptoms of juvenile psychopathy. It is unclear, however, whether CU traits have validity only in the context of conduct disorder (CD) as proposed by Frick and Moffitt (A proposal to the DSM-V childhood disorders and the ADHD and disruptive behavior disorders work groups to include a specifier to the diagnosis of conduct disorder based on the presence of callous-unemotional traits, American Psychiatric Association, Washington, DC, 2010), or also outside CD, either in combination with other forms of psychopathology or as a stand-alone construct.

METHODS

The current review systematically studied the existent literature on CU traits in juveniles to examine their validity inside and outside CD according to the framework regarding the validity of a psychiatric diagnosis provided by Robins and Guze (Am J Psychiatry 126:983-987, 1970).

RESULTS

Inside youth with conduct problems, and CD specifically, it seems that CU traits meet the Robins and Guze criteria. As many of the reviewed studies included youth with ODD and ADHD as well, there are indications the same might be true for ODD and ADHD, although probably to a lesser extent. In other disorders, CU traits may be present as well, but their role is not firmly established. As stand-alone construct, data are lacking or are scarce on all of the above-mentioned criteria.

CONCLUSIONS

CU traits are a useful specifier in CD, and possibly also in disruptive behaviour disorders (DBDs) more generally. High CU traits outside DBDs exist but it is as yet unknown if there is a clinical need for defining CU traits as a stand-alone construct.