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.

The Impact of the COVID-19 Pandemic on Children's Conduct Problems and Callous-Unemotional Traits

The COVID-19 pandemic has dramatically altered family life, but whether family exposures to and worries about the COVID-19 pandemic has impacted child conduct problems (CP) and callous-unemotional (CU) traits is unknown. Thus, we evaluated 303 parents (Mage = 38.04; SD = 5.21; 92.4% biological mothers) and children (Mage = 6.43; SD = 2.13; 51.8% female) during a four-month period early in the pandemic. We examined associations between parental exposures to COVID-19, parental worries about the pandemic, harsh and warm parenting practices, and child CP and CU traits. Although more parental worries were not directly related to parenting practices, more worry about COVID-19 was specifically related to higher levels of child CP, particularly parental worries about themselves or family members contracting the virus. Our findings add to a growing literature demonstrating the burden that the pandemic has placed on families and its implications for children's mental health.

Across-subjects multiple baseline trial of exposure-based cognitive-behavioral therapy for severe irritability: a study protocol

INTRODUCTION

Irritability is defined as a tendency towards anger in response to frustration. Clinically, impairing irritability is a significant public health problem. There is a need for mechanism-based psychotherapies targeting severe irritability as it manifests in the context of disruptive mood dysregulation disorder (DMDD). This study protocol describes a randomised multiple baseline design testing the preliminary efficacy of a new treatment, exposure-based cognitive-behavioral therapy for severe irritability in youth, which also integrates components of parent management training. We will investigate associations of this intervention with primary clinical measures, as well as ecological momentary assessment measures.

METHODS AND ANALYSIS

Forty youth will be enrolled. Participants, aged 8-17 years, must present at least one of two core symptoms of DMDD: abnormal mood or increased reactivity to negative emotional stimuli, with severe impairment in one domain (home, school, peers) and moderate in another, or moderate impairment in at least two domains. Each participant is randomised to a 2-week, 4-week or 6-week baseline observation period, followed by 12 active treatment sessions. Clinical ratings are conducted at baseline, biweekly (clinician), weekly (parent/child) throughout treatment, post-treatment, and 3-month and 6-month follow-up (clinician). Clinician ratings on the Affective Reactivity Index and Clinical Global Impressions-Improvement scale for DMDD are our primary outcome measures. Secondary outcome measures include parent and child reports of irritability. Post hoc additional symptom measures include clinician, parent and self-ratings of depression, anxiety and overall functional impairment. Prospective, digitally based event sampling of symptoms is acquired for a week pre-treatment, mid-treatment and post-treatment. Based on our pathophysiological model of irritability implicating frustrative non-reward, aberrant threat processing and instrumental learning, we probe these three brain-based targets using functional MRI paradigms to assess target engagement.

ETHICS AND DISSEMINATION

The research project and all related materials were submitted and approved by the appropriate Institutional Review Board (IRB) of the National Institute of Mental Health (NIMH).

TRIAL REGISTRATION NUMBERS

NCT02531893 and NCT00025935.

Low social affiliation predicts increases in callous-unemotional behaviors in early childhood

BACKGROUND

Callous-unemotional (CU) behaviors predict risk for aggression and rule-breaking. Low social affiliation (i.e. reduced motivation for and enjoyment of social closeness) is hypothesized to be a phenotypic marker for CU behaviors in early childhood. However, studies need to establish observational methods to objectively assess social affiliation as well as to establish parenting practices that can buffer pathways from low social affiliation to CU behaviors.

METHODS

Using data from a longitudinal twin study of 628 children (age 2, 47% females; age 3, 44.9% females), we examined reciprocal associations between observed social affiliation, CU behaviors, and oppositional-defiant behaviors. We tested whether positive parenting moderated associations over time.

RESULTS

We established that an observed measure of social affiliation derived from the Bayley's Behavior Rating Scale and Infant Behavior Record showed high inter-rater reliability and expected convergence with parent-reported temperament measures. Lower social affiliation at age 2 uniquely predicted CU behaviors, but not oppositional-defiant behaviors, at age 3. Finally, low social affiliation at age 2 predicted CU behaviors at age 3 specifically among children who experienced low, but not high, levels of parental positivity.

CONCLUSIONS

An objective rating scale that is already widely used in pediatric settings reliably indexes low social affiliation and risk for CU behaviors. The dynamic interplay between parenting and low child social affiliation represents an important future target for novel individual- and dyadic-targeted treatments to reduce risk for CU behaviors.

Persistent Frustration-Induced Reconfigurations of Brain Networks Predict Individual Differences in Irritability

OBJECTIVE

Aberrant responses to frustration are central mechanisms of pediatric irritability, which is a common reason for psychiatric consultation and a risk factor for affective disorders and suicidality. This pilot study aimed to characterize brain network configuration during and after frustration and test whether characteristics of networks formed during or after frustration relate to irritability.

METHOD

During functional magnetic resonance imaging, a transdiagnostic sample enriched for irritability (N = 66, mean age = 14.0 years, 50% female participants) completed a frustration-induction task flanked by pretask and posttask resting-state scans. We first tested whether and how the organization of brain regions (ie, nodes) into networks (ie, modules) changes during and after frustration. Then, using a train/test/held-out procedure, we aimed to predict past-week irritability from global efficiency (Eglob) (ie, capacity for parallel information processing) of these modules.

RESULTS

Two modules present in the baseline pretask resting-state scan (one encompassing anterior default mode and temporolimbic regions and one consisting of frontoparietal regions) contributed most to brain circuit reorganization during and after frustration. Only Eglob of modules in the posttask resting-state scans (ie, after frustration) predicted irritability symptoms. Self-reported irritability was predicted by Eglob of a frontotemporal-limbic module. Parent-reported irritability was predicted by Eglob of ventral-prefrontal-subcortical and somatomotor-parietal modules.

CONCLUSION

These pilot results suggest the importance of the postfrustration recovery period in the pathophysiology of irritability. Eglob in 3 specific posttask modules, involved in emotion processing, reward processing, or motor function, predicted irritability. These findings, if replicated, could represent specific intervention targets for irritability.

Integrating the study of personality and psychopathology in the context of gene-environment correlations across development

OBJECTIVE

A key principle of individual differences research is that biological and environmental factors jointly influence personality and psychopathology. Genes and environments interact to influence the emergence and stability of both normal and abnormal behavior (i.e., genetic predisposition, X, is exacerbated or buffered under environmental conditions, Y, or vice versa), including by shaping the neural circuits underpinning behavior. The interplay of genes and environments is also reflected in various ways in which they are correlated (i.e., rGE). That is, the same genetic factors that give rise to personality or psychopathology also shape that person's environment.

METHODS

In this review, we outline passive, evocative, and active rGE processes and review the findings of studies that have addressed rGE in relation to understanding individual differences in personality and psychopathology across development.

RESULTS

Throughout, we evaluate the question of whether it is possible, not only to differentiate the person from their problems, but also to differentiate the person from their problems and their environment.

CONCLUSIONS

We provide recommendations for future research to model rGE and better inform our ability to study personality and psychopathology, while separating the influence of the environment.

Prospective associations between pandemic-related adversity, harsh parenting, and the development of prosociality across middle to late childhood

Parenting behaviors and children's prosociality (i.e., voluntary behaviors intended to benefit others) are linked across development. Contextual risk and environmental stressors may undermine parenting behaviors known to promote children's prosocial behavior. The COVID-19 pandemic provides a unique context in which to examine how stress and contextual risk disrupt parenting practices and the development of children's prosociality over time. To explore the associations between pandemic-related adversity, parenting practices, and child prosocial behavior, we used survey data from 303 families (child Mage = 6.43; 51.4% female, 48.6% male; 65.7% White) who participated in a three-wave longitudinal study during the first year of the pandemic. Families were recruited from two northeastern cities in the United States. Growth mixture modeling identified two groups of parents who varied in their experience of pandemic-related adversity. The high-adversity group reported significantly more symptoms of depression and anxiety, parental burnout, and pandemic-related worries than the low-adversity group. At baseline, parents in the high-adversity group reported harsher parenting and perceived less prosocial behavior in their children. Across the full sample, there were no significant changes in harsh parenting and parental perceptions of child's prosociality across the first year of the pandemic. However, within the high-adversity group, increases in harsh parenting were related to reductions in children's prosociality over time. Results are interpreted in the context of family systems theory and contribute to our understanding of the links between parenting and children's prosociality and patterns of risk and resilience in the context of the COVID-19 pandemic. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Psychometric Properties, Factor Structure, and Validity of the Sensitivity to Threat and Affiliative Reward Scale in Children and Adults

Callous-Unemotional (CU) traits identify children at high risk of antisocial behavior. A recent theoretical model proposed that CU traits arise from low sensitivity to threat and affiliation. To assess these dimensions, we developed the parent- and self-reported Sensitivity to Threat and Affiliative Reward Scale (STARS) and tested its psychometric properties, factor structure, and construct validity. Samples 1 (N =3 03; age 3-10; United States) and 2 (N = 854 age 5-9; Spain) were children and Sample 3 was 514 young adults (Mage = 19.89; United States). In Sample 1, differential item functioning and item response theory techniques were used to identify the best-performing items from a 64-item pool, resulting in 28 items that functioned equivalently across age and gender. Factor analysis indicated acceptable fit for the theorized two-factor structure with separate threat and affiliation factors in all three samples, which showed predictive validity in relation to CU traits in children and psychopathic traits in young adults.

Callous-unemotional traits, cognitive functioning, and externalizing problems in a propensity-matched sample from the ABCD study

BACKGROUND

Many studies show that both callous-unemotional (CU) traits (e.g., low empathy, lack of guilt) and cognitive difficulties increase risk for externalizing psychopathology across development. However, other work suggests that some aggression (e.g., relational, proactive) may rely on intact cognitive function, which could vary based on the presence of CU traits. Moreover, no prior research has adequately accounted for common risk factors shared by CU traits, cognitive difficulties, and externalizing problems, which confounds conclusions that can be drawn about their purported relationships. The current study addressed these knowledge gaps by leveraging rigorous propensity matching methods to isolate associations between CU traits and different dimensions of cognitive function and externalizing problems.

METHODS

Associations between CU traits, cognitive functioning, and externalizing outcomes were tested within dimensional (n = 11,868) and propensity-matched group-based (n = 1,224) models using data from the Adolescent Brain Cognitive Development Study®, with rigorous statistical control for shared sociodemographic risk factors. Cross-sectional outcomes were parent-reported symptoms of conduct disorder (CD), oppositional defiant disorder (ODD), and attention deficit hyperactivity disorder (ADHD). Longitudinal outcomes were child-reported overt and relational aggression.

RESULTS

CU traits were uniquely related to more parent-reported CD, ODD, ADHD symptoms, as well as more child-reported aggressive behaviors. Effects of cognitive difficulties were domain specific and were not consistent across dimensional and propensity matched models. There was minimal evidence for divergent associations between CU traits and externalizing outcomes as a function of cognition (i.e., no moderation).

CONCLUSIONS

Rigorous control for sociodemographic factors within propensity-matched models establish CU traits as a robust and unique risk factor for externalizing psychopathology, over and above difficulties with cognitive functioning.

Contribution of risk and resilience factors to anxiety trajectories during the early stages of the COVID-19 pandemic: A longitudinal study

The COVID-19 pandemic, and the response of governments to mitigate the pandemic's spread, resulted in exceptional circumstances that comprised a major global stressor, with broad implications for mental health. We aimed to delineate anxiety trajectories over three time-points in the first 6 months of the pandemic and identify baseline risk and resilience factors that predicted anxiety trajectories. Within weeks of the pandemic onset, we established a website (covid19resilience.org), and enrolled 1362 participants (n = 1064 from US; n = 222 from Israel) who provided longitudinal data between April-September 2020. We used latent growth mixture modelling to identify anxiety trajectories and ran multivariate regression models to compare characteristics between trajectory classes. A four-class model best fit the data, including a resilient trajectory (stable low anxiety) the most common (n = 961, 75.08%), and chronic anxiety (n = 149, 11.64%), recovery (n = 96, 7.50%) and delayed anxiety (n = 74, 5.78%) trajectories. Resilient participants were older, not living alone, with higher income, more education, and reported fewer COVID-19 worries and better sleep quality. Higher resilience factors' scores, specifically greater emotion regulation and lower conflict relationships, also uniquely distinguished the resilient trajectory. Results are consistent with the pre-pandemic resilience literature suggesting that most individuals show stable mental health in the face of stressful events. Findings can inform preventative interventions for improved mental health.

Evaluating the sensitivity to threat and affiliative reward (STAR) model in relation to the development of conduct problems and callous-unemotional traits across early adolescence

BACKGROUND

The Sensitivity to Threat and Affiliative Reward (STAR) model proposes low threat sensitivity and low affiliation as risk factors for callous-unemotional (CU) traits. Preliminary evidence for the STAR model comes from work in early childhood. However, studies are needed that explore the STAR dimensions in late childhood and adolescence when severe conduct problems (CP) emerge. Moreover, it is unclear how variability across the full spectrum of threat sensitivity and affiliation gives rise to different forms of psychopathology beyond CU traits.

METHODS

The current study addressed these gaps using parent- and child-reported data from three waves and a sub-study of the Adolescent Brain Cognitive Development Study® of 11,878 youth (48% female; ages 9-12).

RESULTS

Consistent with the STAR model, low threat sensitivity and low affiliation were independently related to CU traits across informants and time. Moreover, there was significant interaction between the STAR dimensions, such that children with lower sensitivity to threat and lower affiliation had higher parent-reported CU traits. Unlike CU traits, children with higher threat sensitivity had higher parent-reported CP and anxiety. Finally, children with lower affiliation had higher parent-reported CP, anxiety, and depression. Results largely replicated across informants and time, and sensitivity analysis revealed similar findings in children with and without DSM-5 defined CP.

CONCLUSIONS

Results support the STAR model hypotheses as they pertain to CU traits and delineate threat sensitivity and affiliation as independent transdiagnostic risk factors for different types of psychopathology. Future research is needed to develop fuller and more reliable and valid measures of affiliation and threat sensitivity across multiple assessment modalities.

Longitudinal analysis of the ABCD® study

The Adolescent Brain Cognitive Development® (ABCD) Study provides a unique opportunity to investigate developmental processes in a large, diverse cohort of youths, aged approximately 9-10 at baseline and assessed annually for 10 years. Given the size and complexity of the ABCD Study, researchers analyzing its data will encounter a myriad of methodological and analytical considerations. This review provides an examination of key concepts and techniques related to longitudinal analyses of the ABCD Study data, including: (1) characterization of the factors associated with variation in developmental trajectories; (2) assessment of how level and timing of exposures may impact subsequent development; (3) quantification of how variation in developmental domains may be associated with outcomes, including mediation models and reciprocal relationships. We emphasize the importance of selecting appropriate statistical models to address these research questions. By presenting the advantages and potential challenges of longitudinal analyses in the ABCD Study, this review seeks to equip researchers with foundational knowledge and tools to make informed decisions as they navigate and effectively analyze and interpret the multi-dimensional longitudinal data currently available.

Genetic versus environmental influences on callous-unemotional traits in preadolescence: The role of parenting and parental psychopathology

Children with callous-unemotional (CU) traits are at risk for severe conduct problems. While CU traits are moderately heritable, parenting also predicts risk. However, few studies have investigated whether parenting factors (e.g., acceptance, conflict, parental psychopathology) moderate the etiology of CU traits, while accounting for gene-environment correlations. To address this knowledge gap, we used data from 772 twin pairs from the Adolescent Brain and Cognitive Development Study to test bivariate models that explored overlapping etiological influences on CU traits and child reports of their parenting environment. We also used gene-by-environment interaction models to test whether parenting moderated genetic versus environmental influences. There were no overlapping etiological influences on CU traits and parental acceptance, but modest genetic and non-shared environmental overlap between CU traits and family conflict. Parental acceptance and psychopathology moderated non-shared environmental influences, with stronger non-shared environmental influences on CU traits among children who experienced lower parental acceptance and greater parental psychopathology. Family conflict only moderated environmental influences when models did not covary for conduct problems. Parental acceptance and parental psychopathology may be specific environmental protective and risk factors for CU traits, whereas family conflict may represent a general environmental risk factor for both CU traits and conduct problems.

Parasympathetic Nervous System Functioning Moderates the Associations between Callous-Unemotional Traits and Emotion Understanding Difficulties in Late Childhood

BACKGROUND

Callous-unemotional (CU) traits are characterized by low empathy, guilt, and prosociality, putting children at risk for lifespan antisocial behavior. Elevated CU traits have been linked separately to difficulties with emotion understanding (i.e., identifying emotional states of others) and disrupted parasympathetic nervous system (PNS) functioning. However, no study has investigated how PNS functioning and emotion understanding are jointly related to CU traits.

METHOD

We explored associations between CU traits, emotion understanding, and PNS functioning (indexed via respiratory sinus arrhythmia [RSA]) among children aged 7-10 years old (n = 55). We also tested whether deficits in emotion understanding differ across specific emotions (i.e., fear, pain, happiness, anger). Each child's RSA was continuously recorded while they watched a film that included emotionally evocative social interactions. To assess emotion understanding, children identified emotions replayed in 1s animations of scenes from the film. Parents reported on child CU traits, conduct problems, and demographic information.

RESULTS

Higher CU traits were related to lower emotion understanding (β = -0.43, p = 0.03). PNS activity during the film moderated this association (β = -0.47, p < 0.001), such that CU traits were associated with lower emotion understanding among children with mean (B = -0.01, t = -2.46, p = 0.02) or high (i.e., 1 SD > M; B = -0.02, t = -3.00, p < 0.001) RSA levels during the film, but not among children with low RSA levels (i.e., 1 SD < M; B = 0.00, t = -0.53, p = 0.60). Moreover, we found that the observed moderated associations are driven by deficits in fear, specifically.

CONCLUSIONS

The link between poorer emotion understanding, fear understanding in particular, and CU traits was attenuated for children who demonstrated patterns of PNS functioning consistent with attentional engagement while viewing the emotion stimuli.

Unique versus shared neural correlates of externalizing psychopathology in late childhood

Childhood externalizing psychopathology is heterogeneous. Symptom variability in conduct disorder (CD), oppositional defiant disorder (ODD), attention-deficit/hyperactivity disorder (ADHD), and callous-unemotional (CU) traits designate different subgroups of children with externalizing problems who have specific treatment needs. However, CD, ODD, ADHD, and CU traits are highly comorbid. Studies need to generate insights into shared versus unique risk mechanisms, including through the use of functional magnetic resonance imaging (fMRI). In this study, we tested whether symptoms of CD, ODD, ADHD, and CU traits were best represented within a bifactor framework, simultaneously modeling shared (i.e., general externalizing problems) and unique (i.e., symptom-specific) variance, or through a four-correlated factor or second-order factor model. Participants (N = 11,878, age, M = 9 years) were from the Adolescent Brain and Cognitive Development Study. We used questionnaire and functional magnetic resonance imaging data (emotional N-back task) from the baseline assessment. A bifactor model specifying a general externalizing and specific CD, ODD, ADHD, and CU traits factors demonstrated the best fit. The four-correlated and second-order factor models both fit the data well and were retained for analyses. Across models, reduced right amygdala activity to fearful faces was associated with more general externalizing problems and reduced dorsolateral prefrontal cortex activity to fearful faces was associated with higher CU traits. ADHD scores were related to greater right nucleus accumbens activation to fearful and happy faces. Results give insights into risk mechanisms underlying comorbidity and heterogeneity within externalizing psychopathology. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Treatment adherence, therapeutic alliance, and clinical outcomes during an exposure-based cognitive-behavioral therapy for pediatric irritability

BACKGROUND

This study explores changes in treatment adherence and alliance during a novel parent- and child-psychotherapy for pediatric irritability. Associations between in-session therapeutic processes and symptom change were examined.

METHODS

Forty participants (Mean age = 11.23, SD = 1.85; 37.5% female, 77.5% white) with severe irritability, and their parents, received 12 sessions of exposure-based cognitive behavioral therapy (CBT) with parent management training (PMT). Measures included clinician-rated adherence to the manual, alliance scales (Alliance Scale for Children-revised; TASC-r, and Working Alliance Inventory; WAI, respectively), and clinician-, parent- and child-reported irritability scales (Affective Reactivity Index; ARI). Linear mixed models examined session-by-session changes and associations between adherence/alliance and subsequent irritability, and vice versa.

RESULTS

First, adherence to standard treatment elements decreased over time (Bs ≥ - 0.03, ps ≤ 0.010), while the focus on specific treatment components increased (i.e., exposure: B = 0.15, p = 0.001; PMT: B = 0.07, p = 0.002). Second, adherence to standard treatment elements were associated with decreased clinician-reported irritability (Bs ≥ - 2.23, p ≤ 0.042). For the alliance measures, parent-reported alliance increased over time (Bs ≥ 0.10, p ≤ 0.01); child-reported alliance did not change. Bidirectional associations were found between alliance and symptoms; specifically, child-reported alliance predicted clinician-rated irritability at next session (Bs ≥ - 0.66, p ≤ 0.053), and decreases in clinician- (Bs ≥ - 0.02, ps ≤ 0.043) and parent- (B = - 0.15, p = 0.024) reported irritability predicted increased alliance at next session.

CONCLUSIONS

Findings underscore the predictive role of treatment adherence and therapeutic alliance on outcomes, in exposure-based CBT for pediatric irritability.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02531893; date of registration: 25/08/2015.