The usefulness of DSM-IV and DSM-5 conduct disorder subtyping in detained adolescents

Impaired Punishment Learning in Conduct Disorder

OBJECTIVE

Conduct disorder (CD) has been associated with deficits in the use of punishment to guide reinforcement learning (RL) and decision making. This may explain the poorly planned and often impulsive antisocial and aggressive behavior in affected youths. Here, we used a computational modeling approach to examine differences in RL abilities between CD youths and typically developing controls (TDCs). Specifically, we tested 2 competing hypotheses that RL deficits in CD reflect either reward dominance (also known as reward hypersensitivity) or punishment insensitivity (also known as punishment hyposensitivity).

METHOD

The study included 92 CD youths and 130 TDCs (aged 9-18 years, 48% girls) who completed a probabilistic RL task with reward, punishment, and neutral contingencies. Using computational modeling, we investigated the extent to which the 2 groups differed in their learning abilities to obtain reward and/or to avoid punishment.

RESULTS

RL model comparisons showed that a model with separate learning rates per contingency explained behavioral performance best. Importantly, CD youths showed lower learning rates than TDCs specifically for punishment, whereas learning rates for reward and neutral contingencies did not differ. Moreover, callous-unemotional (CU) traits did not correlate with learning rates in CD.

CONCLUSION

CD youths have a highly selective impairment in probabilistic punishment learning, regardless of their CU traits, whereas reward learning appears to be intact. In summary, our data suggest punishment insensitivity rather than reward dominance in CD. Clinically, the use of punishment-based intervention techniques to achieve effective discipline in patients with CD may be a less helpful strategy than reward-based techniques.

Neural processing of socioemotional content in conduct-disordered juvenile offenders with limited prosocial emotions

BACKGROUND

Reflecting evidence on Callous-Unemotional (CU) traits (e.g., lack of empathy and guilt, shallow affect), the DSM-5 added a categorical CU-based specifier for Conduct Disorder (CD), labeled 'with Limited Prosocial Emotions' (LPE). Theory and prior work suggest that CD youths with and without LPE will likely differ in neural processing of negative socioemotional content. This proposition, however, is mainly derived from studies employing related, yet distinct, operationalizations of CU traits (e.g., dimensional measure/median split/top quartile), thus precluding direct examination of LPE-specific neurocognitive deficits.

METHODS

Employing a DSM-5 informed LPE proxy, neural processing of recognizing and resonating negative socioemotional content (angry and fearful faces) was therefore examined here among CD offenders with LPE (CD/LPE+; N = 19), relative to CD offenders without LPE (CD/LPE-; N = 31) and healthy controls (HC; N = 31).

RESULTS

Relative to HC and CD/LPE- youths and according to a linearly increasing trend (CD/LPE- < HC < CD/LPE+), CD/LPE+ youths exhibited hyperactivity within dorsolateral, dorsomedial, and ventromedial prefrontal regions during both emotion recognition and resonance. During emotion resonance, CD/LPE+ youths additionally showed increased activity within the posterior cingulate and precuneal cortices in comparison to HC and CD/LPE- youths, which again followed a linearly increasing trend (CD/LPE- < HC < CD/LPE+). These effects moreover seemed specific to the LPE specifier, when compared to a commonly employed method for CU-based grouping in CD (i.e., median split on CU scores).

CONCLUSIONS

These data cautiously suggest that CD/LPE+ youths may exhibit an over-reliance on cortical neurocognitive systems when explicitly processing negative socioemotional information, which could have adverse downstream effects on relevant socioemotional functions. The findings thus seem to provide novel, yet preliminary, clues on the neurocognitive profile of CD/LPE+, and additionally highlight the potential scientific utility of the LPE specifier.

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

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

Neuropsychological Subgroups of Emotion Processing in Youths With Conduct Disorder

Background: At the group level, youths with conduct disorder (CD) show deficient emotion processing across various tasks compared to typically developing controls (TDC). But little is known about neuropsychological subgroups within the CD population, the clinical correlates of emotion processing deficits [for instance, with regard to the presence or absence of the DSM-5 Limited Prosocial Emotions (LPE) specifier], and associated risk factors. Methods: 542 children and adolescents with CD (317 girls) and 710 TDCs (479 girls), aged 9-18 years, were included from the FemNAT-CD multisite study. All participants completed three neuropsychological tasks assessing emotion recognition, emotion learning, and emotion regulation. We used a self-report measure of callous-unemotional traits to create a proxy for the LPE specifier. Results: Relative to TDCs, youths with CD as a group performed worse in all three emotion domains. But using clinically based cut-off scores, we found poor emotion recognition skills in only 23% of the participants with CD, followed by emotion regulation deficits in 18%, and emotion learning deficits in 13% of the CD group. Critically, the majority of youths with CD (~56%) did not demonstrate any meaningful neuropsychological deficit, and only a very small proportion showed pervasive deficits across all three domains (~1%). Further analyses indicate that established DSM-5 subtypes of CD are not tightly linked to neurocognitive deficits in one particular emotion domain over another (i.e., emotion recognition deficits in CD+LPE vs. emotion regulation deficits in CD-LPE). Conclusions: Findings from this large-scale data set suggest substantial neuropsychological diversity in emotion processing in the CD population and, consequently, only a subgroup of youths with CD are likely to benefit from additional behavioral interventions specifically targeting emotion processing mechanisms.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The validity of conduct disorder symptom profiles in high-risk male youth

Conduct disorder (CD) is a heterogeneous pattern of rule-breaking and aggressive symptoms. Until now it has been unclear whether valid, clinically useful symptom profiles can be defined for populations in youth at high-risk of CD. Interview-based psychiatric disorders, CD symptoms and officially recorded offences were assessed in boys from a detention facility and a forensic psychiatric hospital (N = 281; age 11.2-21.3 years). We used latent class analyses (LCA) to examine CD subtypes and their relationships with comorbid psychiatric disorders, suicidality, and criminal recidivism. LCA revealed five CD subtypes: no CD, mild aggressive CD, mild covert CD, moderate CD, and severe CD. The severe and, to a lesser degree, the moderate CD subtype were related to comorbid attention deficit hyperactivity disorder, substance use disorder, affective disorder, and suicidality. Time to violent criminal re-offending was predicted by severe CD (OR 5.98, CI 2.5-13.80) and moderate CD (OR 4.18, CI 1.89-9.21), but not by any other CD subtype in multivariate Cox regressions (controlling for age, low socioeconomic status and foreign nationality). These results confirm the existence of different CD symptom profiles in a high-risk group. Additional variable-oriented analyses with CD symptom count and aggressive/rule-breaking CD-dimensions further supported a dimensional view and a dose-response relationship of CD and criminal recidivism. Classifying high-risk young people according to the number of aggressive and rule-breaking CD symptoms is of major clinical importance and may provide information about risk of violent recidivism.

Taxometric analyses and predictive accuracy of callous-unemotional traits regarding quality of life and behavior problems in non-conduct disorder diagnoses

Callous-unemotional (CU) traits have mainly been studied in relation to conduct disorder (CD), but can also occur in other disorder groups. However, it is unclear whether there is a clinically relevant cut-off value of levels of CU traits in predicting reduced quality of life (QoL) and clinical symptoms, and whether CU traits better fit a categorical (taxonic) or dimensional model. Parents of 979 youths referred to a child and adolescent psychiatric clinic rated their child's CU traits on the Inventory of Callous-Unemotional traits (ICU), QoL on the Kidscreen-27, and clinical symptoms on the Child Behavior Checklist. Experienced clinicians conferred DSM-IV-TR diagnoses of ADHD, ASD, anxiety/mood disorders and DBD-NOS/ODD. The ICU was also used to score the DSM-5 specifier 'with limited prosocial emotions' (LPE) of Conduct Disorder. Receiver operating characteristic (ROC) analyses revealed that the predictive accuracy of the ICU and LPE regarding QoL and clinical symptoms was poor to fair, and similar across diagnoses. A clinical cut-off point could not be defined. Taxometric analyses suggested that callous-unemotional traits on the ICU best reflect a dimension rather than taxon. More research is needed on the impact of CU traits on the functional adaptation, course, and response to treatment of non-CD conditions.

Imaging decision about whether to benefit self by harming others: Adolescents with conduct and substance problems, with or without callous-unemotionality, or developing typically

We sought to identify brain activation differences in conduct-problem youth with limited prosocial emotions (LPE) compared to conduct-problem youth without LPE and community adolescents, and to test associations between brain activation and severity of callous-unemotional traits. We utilized a novel task, which asks subjects to repeatedly decide whether to accept offers where they will benefit but a beneficent other will be harmed. Behavior on this task has been previously associated with levels of prosocial emotions and severity of callous-unemotional traits, and is related to empathic concern. During fMRI acquisition, 66 male adolescents (21 conduct-problem patients with LPE, 21 without, and 24 typically-developing controls) played this novel game. Within typically-developing controls, we identified a network engaged during decision involving bilateral insula, and inferior parietal and medial frontal cortices, among other regions. Group comparisons using non-parametric (distribution-free) permutation tests demonstrated LPE patients had lower activation estimates than typically-developing adolescents in right anterior insula. Additional significant group differences emerged with our a priori parametric cluster-wise inference threshold. These results suggest measurable functional brain activation differences in conduct-problem adolescents with LPE compared to typically-developing adolescents. Such differences may underscore differential treatment needs for conduct-problem males with and without LPE.

"A Psychopath by Any Other Name?": Juror Perceptions of the DSM-5 "Limited Prosocial Emotions" Specifier

DSM-5 recently added the specifier "Limited Prosocial Emotions" (LPE) to the Conduct Disorder (CD) diagnosis, yet little is known about how these traits will affect attitudes toward CD youth. Laypersons attending jury duty (N = 326) were randomly assigned to one of four case vignette conditions in which a male juvenile offender was identified as having (a) CD symptoms only, (b) CD symptoms plus a diagnostic label, (c) CD symptoms plus a diagnostic label and description of LPE traits, or (d) CD symptoms plus a description of LPE traits and a "psychopath" label. LPE traits led to more negative perceptions of the youth (e.g., more dangerous, evil, and psychopathic) and adding the psychopath label to the LPE specifier resulted in somewhat stronger support for punishment and mandated treatment. The LPE specifier may provide useful diagnostic information, but these findings raise serious concerns that it will stigmatize youth in the legal system.

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

Although treatment engagement (TE) is crucial for treatment success it is not well known how likely detained girls are to engage in treatment and what features may impede them from doing so. This study is the first to examine the prognostic usefulness of two features of potential interest, being callous-unemotional (CU) traits and conduct disorder (CD), in relation to TE. Detained girls and their parents (n = 75) were interviewed with the Diagnostic Interview Schedule for Children to assess CD, and completed the Antisocial Process Screening Device to assess CU traits dimensionally and categorically as in the new diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) CU-based specifier. One to two months later, the girls reported how much they engaged in treatment. At the zero-order level, self-, but not parent-reported CU traits and CD were predictive of lower levels of TE. The incorporation of CU traits into a diagnosis of CD identified girls with lower levels of future TE, a finding that held across different informants. Of note, the aforementioned findings only became apparent when using a dimensional measure of CU traits, and not when using the categorical measure of CU traits currently included in DSM-5. This study showed that CU traits can help developing an understanding of what factors hinder TE among detained girls. Our findings also support recommendations to incorporate CU traits into the CD diagnosis, and suggest that dimensional approaches to do so may yield relevant information about future levels of TE.

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

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

Exploring the clinical utility of the DSM-5 conduct disorder specifier of 'with limited prosocial emotions' in an adolescent inpatient sample

BACKGROUND

With the recent addition of a callous-unemotional (CU) specifier to the diagnosis of conduct disorder (CD) in the DSM-5, studies are needed to evaluate the clinical utility of this specifier and the best ways to identify youth meeting criteria for this specifier in clinical samples.

METHODS

To this end, the current study examined cross-sectional correlates and treatment response across four groups of inpatient adolescents (N=382, ages 12-17): those with CD without the specifier, with CD and the CU specifier, CU alone, and a group of psychiatric controls. We used two different measures to identify adolescents with high levels of CU traits: the Antisocial Process Screening Device (APSD) [1] and the Inventory of Callous-Unemotional Traits (ICU) [2]. Questionnaires and structured interviews were used to evaluate a range of outcomes including presence of baseline levels and treatment outcomes of both externalizing and internalizing problems.

FINDINGS

Results indicated that the ICU, but not the APSD differentiated between conduct disordered youth with and without the specifier on externalizing behaviors in both cross-sectional relations and treatment response.

CONCLUSIONS

The results of the current study caution the use of the most frequently used measure to identify the CU specifier, and make suggestions about alternatives.

Adolescent Male Conduct-Disordered Patients in Substance Use Disorder Treatment: Examining the "Limited Prosocial Emotions" Specifier

To our knowledge, this is the first study to examine the DSM-5-defined conduct disorder (CD) with limited prosocial emotions (LPE) among adolescents in substance use disorder (SUD) treatment, despite the high rates of CD in this population. We tested previously published methods of LPE categorization in a sample of male conduct-disordered patients in SUD treatment (n=196). CD with LPE patients did not demonstrate a distinct pattern in terms of demographics or co-morbidity regardless of the categorization method utilized. In conclusion, LPE, as operationalized here, does not identify a distinct subgroup of patients based on psychiatric comorbidity, SUD diagnoses, or demographics.

The DSM-5 Limited Prosocial Emotions subtype of Conduct Disorder in incarcerated male and female juvenile delinquents

The aim of the present study was to analyze the relevance of the DSM-5's Conduct Disorder new Limited Prosocial Emotions (CD LPE) specifier in incarcerated juvenile delinquents. A sample of 201 males and 98 females from the Juvenile Detention Centers managed by the Portuguese Ministry of Justice diagnosed with Conduct Disorder (CD) was used. Results showed that male juvenile delinquents with the CD LPE specifier scored higher on callous-unemotional traits (CU), general psychopathic traits, psychopathy taxon membership, self-reported delinquency, and crime seriousness, and lower on prosocial behavior and social desirability, while female juvenile delinquents with the CD LPE specifier scored higher on callous-unemotional traits (CU) and general psychopathic traits, and lower on prosocial behavior. Significant associations for both genders were found between the CD LPE specifier and age of crime onset and first problems with the law.

A New Measure to Assess Psychopathic Personality in Children: The Child Problematic Traits Inventory

Understanding the development of psychopathic personality from childhood to adulthood is crucial for understanding the development and stability of severe and long-lasting conduct problems and criminal behavior. This paper describes the development of a new teacher rated instrument to assess psychopathic personality from age three to 12, the Child Problematic Traits Inventory (CPTI). The reliability and validity of the CPTI was tested in a Swedish general population sample of 2,056 3- to 5-year-olds (mean age = 3.86; SD = .86; 53 % boys). The CPTI items loaded distinctively on three theoretically proposed factors: a Grandiose-Deceitful Factor, a Callous-Unemotional factor, and an Impulsive-Need for Stimulation factor. The three CPTI factors showed reliability in internal consistency and external validity, in terms of expected correlations with theoretically relevant constructs (e.g., fearlessness). The interaction between the three CPTI factors was a stronger predictor of concurrent conduct problems than any of the three individual CPTI factors, showing that it is important to assess all three factors of the psychopathic personality construct in early childhood. In conclusion, the CPTI seems to reliably and validly assess a constellation of traits that is similar to psychopathic personality as manifested in adolescence and adulthood.