Callous–unemotional traits

Serious antisocial behavior, which violates the rights of others (e.g., aggression, destruction of property) or violates major age appropriate norms and rules (e.g., deceitful behavior, truancy, running away from home), is a critical component of the externalizing spectrum of disorders. This is made explicit in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) in which Conduct Disorder (CD) is placed under the broad heading, “Disruptive, Impulse Control, and Conduct Disorders.” All disorders within this category are conditions involving problems in the self-control of emotions and/or behaviors (American Psychiatric Association, 2013). As also explicitly noted in the DSM-5, the underlying causes of problems in self-control can vary greatly across individuals within a given diagnostic category. Accordingly, there has been significant research focused on advancing our knowledge of the most common causes of the problems in self-control exhibited by children and adolescents with CD and on using this knowledge to design more effective treatments for this disorder (Frick, 2016).

In this chapter, we review research on one method for differentiating among the diverse causal processes that can lead to serious antisocial behavior and aggression. It has its roots in the construct of psychopathy that has been used to designate an important subgroup of antisocial adults for much of the past century (Cleckley, 1976; Hare, 1993). Specifically, the construct of psychopathy is defined by a constellation of affective (e.g., lack of guilt and empathy; poverty of emotion), interpersonal (e.g., grandiosity and manipulativeness), and behavioral (e.g., impulsivity and irresponsibility) features that are highly associated with antisocial behavior (Hare & Neumann, 2008). Importantly, research has shown that only a small proportion of antisocial adults show significant levels of psychopathic traits but these offenders exhibit a more severe, violent, and chronic pattern of antisocial behavior (Leistico, Salekin, DeCoster, & Rogers, 2008). Further, antisocial adults with and without psychopathic traits show a host of distinct neurological, cognitive, and emotional characteristics that could implicate different causal factors leading to their antisocial behavior across the two groups (Blair, Mitchell, & Blair, 2005). Thus, the construct of psychopathy has proven to have very important clinical (i.e., prediction of harmful behavior) and etiological (i.e., designating unique causal pathways to antisocial behavior) implications.

Several findings from research on psychopathy led to a desire to study precursors to this serious mental health concern prior to adulthood. First, adults with psychopathic traits typically have long histories of antisocial behavior that begin early in childhood (Forth, 1995). Thus, it was quite possible that this construct could designate a subgroup of antisocial youth that also might show a particularly severe and stable pattern of conduct problems. Second, developmental psychologists had a long history of studying how guilt, empathy, and other moral emotions develop in children (Hoffman, 1970). These affective components to conscience were very similar to the affective components of psychopathy and, as a result, integrating these two bodies of work could potentially expand causal theories for how psychopathy might develop (Frick, 2009). Third, adults with psychopathy tend to be very difficult to treat and often do not respond to many interventions that are successful in reducing antisocial behavior in those without these traits (Salekin, 2002). Further, research has consistently indicated that treatment for antisocial behavior is more successful when it is implemented earlier in development (Frick, 2012). Thus, it is possible that treatments for psychopathic traits would be more successful prior to adulthood as well.

For these reasons, there have been a number of attempts to extend the construct of psychopathy to youth and some of the early approaches were quite promising. That is, children and adolescents with serious conduct problems who also showed significant psychopathic traits tended to have poorer adjustment in juvenile institutions and were more likely to continue to show antisocial behavior into adulthood compared to other adolescents with serious conduct problems (Quay, 1987). Further, the group with psychopathic traits was also more likely to show several neurophysiological correlates to their antisocial behavior, such as low serotonin levels and autonomic irregularities, supporting the possibility that these traits may be important for capturing the heterogeneity in causes of antisocial behavior, similar to the findings in adults (Lahey, Hart, Pliszka, Applegate, & McBurnett, 1993; Quay, 1993).

However, in an attempt to avoid the potential stigma associated with the term “psychopath,” the name that was given to this group of youth was “undersocialized aggressive” (Quay, 1987). Unfortunately, this name resulted in considerable confusion as to the core features for defining this construct and the best way to operationalize these features when assessing children and adolescents (Lahey, Loeber, Quay, Frick, & Grimm, 1992). Some definitions focused on the child’s ability to form and maintain social relationships, whereas others focused primarily on the context (alone or as a group) in which the antisocial acts were typically committed. Very few definitions focused directly on the interpersonal and affective characteristics that were central to the clinical descriptions of psychopathic individuals (Quay, 1987). As a result of this definitional confusion, the use of psychopathy to guide subtyping approaches in children and adolescents was abandoned in order to focus on other aspects of the child’s behavior, such as whether the antisocial acts were committed alone and whether the pattern of antisocial behavior included aggressive symptoms (e.g., solitary aggressive subtype of CD; Lahey et al., 1992). Unfortunately, these definitions led to methods of subtyping children with serious conduct problems that were quite different from either the adult construct of psychopathy (Hare & Neumann, 2008) or developmental definitions of the affective components of conscience (Thompson & Newton, 2010). As a result, the findings from research did not show much convergence to research on adults with psychopathy or with research on the normal processes that lead to the development of prosocial emotions in children (Frick & Viding, 2009).

Paul J. Frick, … Julia E. Clark, in Developmental Pathways to Disruptive, Impulse-Control and Conduct Disorders, 2018

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