Extending the Construct of Psychopathy to Youth:Implications for Understanding, Diagnosing, andTreating Antisocial Children and Adolescents

Paul J Frick,

This paper reviews several attempts to extetid the construct of psychopathy to childreti andadolescents. The research suggests that the presence of callous-unemotional (CU) traitsmay be particularly important. Specifically, the presence of these traits designates aclinically important subgroup of youth with childhood-onset conduct problems who show aparticularly severe, aggressive, and stable pattern of antisocial behaviour. Also, childrenwith CU traits show numerous emotional, cognitive, and personality features that aredistinct from other antisocial youth that are similar to features found in adults withpsychopathy. The research on CU traits has important implications for understanding thedifferent causal pathways through which children develop severe antisocial and aggressivebehaviour, as well as implications for diagnosing and intervening with antisocial youth.

Can J Psychiatry. 2009;54(12):803-812.

Highlights

• The presenee of CU traits seems to designate an important subgroup of youth withchildhood-onset conduct problems who show a more severe, stable, and aggressive pattern ofantisocial behaviour.

• Youth with conduct problems who show CU traits differ from other youth with conductproblems on numerous emotional, cognitive, and personality characteristics; these fmdingssuggest that the 2 groups have distinct causal processes leading to their problem behaviour.

• The eharacteristies of youth with CU traits show many similarities to adults with psychopathy;thus using these traits to designate a subgroup of antisocial youth provides a usefuldevelopmental model for xinderstanding precursors to psychopathy.

Key Words: youth, psychopathy, callous-unemotional traits, developmental pathways,

emotional deficits

The construct of psychopathy has proven to be very impor-tant for designating a distinct and important subgroup ofantisocial adults.' Specifically, only a small proportion ofadult offenders show the affective (for example, lack of guiltand empathy; poverty of emotion), interpersonal (for exam-ple, grandiosity and manipulativeness), and behavioural (forexample, impulsivity and irresponsibility) features that definepsychopathy.^ However, people with these traits exhibit amore severe, violent, and chronic pattern of antisocial behav-iour.̂ '"* Further, antisocial people with significant psycho-pathic features show numerous neurological, cognitive, and

emotional characteristics that seem to suggest that distinct

causal factors lead to their antisocial behaviour, compared

with antisocial adults without psychopathic traits.'"' Based

on this research, the construct of psychopathy is important to

the legal system (for example, defining offenders who are a

high risk for recidivism), to the mental health system (for

example, defining a group of antisocial people who have

unique treatment requirements), and for research attempting

to explain the causes of antisocial and aggressive behaviour

(for example, defining a group of antisocial people with

unique causal processes). Importantly, research has shown

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In Review

that adults with psychopathic traits often have long historiesof antisocial behaviour that often extend well into childhood.*As a result, there have been numerous attempts to definedevelopmental precursors to psychopathy.

Previous Attempts to Subtype Antisocial andAggressive Youth: Implications forDevelopmental Models of PsychopathyChildhood-Onset CDOne method of subtyping children and adolescents with anti-social and aggressive behaviour that has extensive researchsupport is distinguishing between those whose serious behav-iour problems begin before adolescence (that is, thechildhood-onset group) and those whose serious behaviourproblems begin during adolescence (that is, the adolescent-onset group).'-' ' Importantly, children in the childhood-onsetgroup show numerous characteristics that are similar to adultswith psychopathy. First, children in this group tend to showmore severe aggression in adolescence and they are at higherrisk for antisocial and criminal outcomes in adulthood. '̂ Sec-ond, children and adolescents with childhood-onset antisocialbehaviour tend to show more dispositional vulnerabilities (forexample, temperament risk factors and neurocognitive defi-cits) than those in the adolescent-onset group."'"' ' ' Third,children in the childhood-onset group are more likely to showseveral of the affective (for example, lack of guilt and empa-thy) and behavioural (for example, impulsivity) features ofpsychopathy.'^'''''^

Although children and adolescents with childhood-onset anti-social behaviour show many features similar to adults withpsychopathy, there is also evidence that only a subset show apersistent level of antisocial behaviour across adolescenceand adulthood." Further, there are several distinct tempera-mental styles that are found in youth with childhood-onsetconduct problems, only some of which would be consistentwith the construct of psychopathy. Specifically, there appearto be numerous children with childhood-onset conduct prob-lems who show strong emotional arousal, deficits in verbalintelligence, and other cognitive deficits, and who appear tobe distressed by the effects of their behaviour on others.'"''*All of these characteristics are not consistent with the con-struct of psychopathy. Thus there have been attempts to definea subgroup of youth within the larger childhood-onset group

Abbreviations used in this articie

ADHD attention-deficit hyperactivity disorder

CD conduct disorder

CU caiious-unemotional

ICC intraclass correlation coefficient

that may show characteristics more specific to the constructof psychopathy.

Presence of ADHD

One such attempt focuses on the combination of the inatten-tive, impulsive, and hyperactive behaviours associated withADHD, with significant conduct problems and antisocialbehaviour. '̂ In support of this approach, there have been sev-eral reviews indicating that children with both types of prob-lems show a more severe and aggressive pattern of antisocialbehaviour than children with conduct problems alone.^°'^' Inaddition, children with ADHD and conduct problems havepoorer outcomes, such as showing higher rates of delin-quency in adolescence and higher rates of arrests in adult-hood.̂ '̂̂ ^ Further, youth with co-occurring ADHD andconduct problems show deficits on laboratory tasks assessingresponse modulation and delay of gratification, all of whichhave been associated with psychopathic traits in adults.^''

Despite these findings supporting this method of subtypingantisocial youth, there are also some limitations. First, a sub-stantial number of children with childhood-onset conductproblems show co-occurring ADHD; in fact, in many clinicalsamples it is the vast majority of childhood-onset childrenwho show this comorbidity.^^ As a result, this method ofsubtyping often does not designate a group that is very dis-tinct from the broader group deñned by an early age of onset.Second, this method places a primary emphasis on impulsiveand antisocial behaviours, which have not proven to be spe-cific to adults with psychopathy.^*'" That is, impulsive-antisocial tendencies appear to be elevated in most adultswith significant criminal histories and (or) a diagnosis ofantisocial personality disorder. In contrast, what has beencritical to adult definitions of psychopathy are the affectiveand interpersonal characteristics that may accompany thisimpulsive and antisocial lifestyle in some people. There isevidence that the same may be true in children and adoles-cents as well. That is, it appears to be only youth who areimpulsive, antisocial, and who show the affective and inter-personal traits of psychopathy who are most likely to showmany of the cognitive (for example, reward dominance) andpersonality (for example, fearlessness) characteristics thatare similar to adults with psychopathy.^*

Patterns of AggressionAnother method that has been used to subtype childrenwithin the childhood-onset group focuses on the severity andtype of aggression displayed. Specifically, research has indi-cated that 2 forms of aggression can be identified in samplesof children or adolescents with conduct problems.^''^" Reac-tive aggression is characterized by impulsive-defensiveresponses to a perceived provocation or threat and is usuallyaccompanied by a display of intense physiological

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ity.̂ ''̂ ^ In contrast, proactive or instrumental aggres-sion is not associated with provocation but is defined asaggression in pursuit of an instrumental goal and is usuallypremeditated and planned.̂ ^"'" Importantly, studies in chil-dren and adolescents suggest that some youth with conductproblems show only mild levels of reactive aggression,whereas a second group shows high rates of both reactive andinstrumental aggression."''"* This latter group is similar toadult offenders with psychopathic traits who have been shownto be more aggressive overall and to differ fromnonpsychopathic offenders by showing more instrumentaland premeditated

In support of this method of subtyping, research has shownthat children who show instrumental aggression often showdeficits in emotional responding that are similar to thosefound in adults with psychopathic traits (for example, loweremotional arousal to provocation)."'^* Further, children andadolescents with this more pervasive pattern of aggressionhave been shown to have higher rates of CU traits (for exam-ple, lacking guilt and empathy).'^''''' Unfortunately, there arealso 2 limitations with this approach. First, this distinctionrequires a method of distinguishing between the differenttypes of aggression, and such a distinction has proven to bevery hard to make reliably.^' Second, when both types ofaggression and CU traits are assessed in the same sample, itappears that the emotional deficits that are consistently relatedto psychopathy tend to be more specifically related to CUtraits, rather than to the aggressive behaviour."*"

SummaryIn summary, all of these approaches to subtyping youth withserious conduct problems have shown some validity for des-ignating children and adolescents who show characteristicssimilar to adults with psychopathy. However, all of theseapproaches also have some limitations and this is likelybecause they have not focused on the core affective and inter-personal traits that have been key to most definitions of psy-chopathy and, more importantly, that distinguish adults withpsychopathy from other antisocial people. Therefore, it is notsurprising that an approach to subtyping that has shown someof the strongest support for potentially designating a develop-mental precursor to psychopathy focuses directly on making adevelopmental extension of these core features of psychopa-thy to children and adolescents with serious conductproblems.

The Importance of CU TraitsFactor AnalysesThere have been several attempts to assess core features ofpsychopathy, with appropriate developmental modifications,in samples of children and adolescents using several differentassessment formats.''''''^'''' Importantly, in samples of

46

clinic-referred and nonreferred children''^ and in samples ofincarcerated adolescents,'*'' factor analyses have consistentlyidentified 3 personality dimensions, in addition to an antiso-cial behaviour factor, similar to those identified in adult sam-ples. These personality dimensions have been labelled as CU,narcissistic, and impulsive traits. Although all 3 personalitydimensions are often elevated in children and adolescentswho show serious antisocial behaviour, CU traits seems todesignate a specific subgroup of these antisocial youth.Unfortunately, most measures include only a limited numberof items specifically assessing this dimension, often with asfew as 4'*̂ or 6'*' items specifically assessing CU traits. Fur-ther, and possibly owing to this limited item pool, measuresof CU traits often have had some significant psychometriclimitations, such as displaying poor internal consistency insome response formats.''^

A more extended assessment (24 items) of CU traits has beendeveloped and its factor structure has been tested innonreferred samples of adolescents in Germany (« = 1443)'and Greek Cyprus (n = 347)'*' and in a sample of juvenileoffenders in the United States (n = 248).'*^ Across all 3 sam-ples, a very similar bi-factor structure seemed to fit the databest, with a general CU factor accounting for covarianceamong all items and 3 independent subfactors (uncaring, cal-lous, and unemotional) reflecting unique patterns ofcovariance among particular groups of items. The itemsforming these 3 subfactors are provided in Table 1 and illus-trate the features that define the construct of CU traits. Impor-tantly, the total scores from this measure proved to beinternally consistent in all 3 samples (a = 0.77 to 0.81), sug-gesting that this extended measure of CU traits may over-come some of the limitations of past measures with morelimited item content.

Stability

Thus research suggests that CU traits seem to be present in asubgroup of antisocial youth. Importantly, some criticalquestions for assessing these traits in childhood and adoles-cence are: How early can these traits be reliably assessed?How consistent is the measurement structure across develop-ment? and. How stable are these traits prior to adulthood? Toaddress the first question, although most studies havefocused on samples of adolescents,'*''^" there have beennumerous studies of préadolescent children showing CUtraits, with a few studies using samples aged as young as 3and 4 years.^''^^ To address the second question, Obradovicet al" studied the structure of CU traits in a sample of 506boys and found strong support for measurement invariance inparent reports of these traits from ages 8 to 16 years and inteacher reports from ages 11 to 16 years. Such invariancesuggests that the indicators of CU traits were assessing the

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In Review

Table 1 Dimensions of CU traits

Uncaring

I work hard on everything I do. (I)

I always try my best. (I)

I care about how well I do at school or work. (1)̂

I do things to make others feel good. (I)

I apologize (say I am sorry) to persons I hurt. (I)

I feel bad or guilty when I do something wrong. ( I f

I easily admit to being wrong. (I)

I try not to hurt others' feelings. (I)

Callousness

I do not care about doing things well.

I do not like to put the time into doing things well.

I do not feel remorseful when I do something wrong.

I do not care about being on time.

I do not care if I get into trouble.

I seem very cold and uncaring to others.

The feelings of others are unimportant to me.

I do not care who I hurt to get what I want.

I am concerned about the feelings of others. (1)̂

I do not like to put the time into doing things well.

What I think is right and wrong is different from what otherpeople think.

Unemotional

I do not show my emotions to others.^

I express my feelings openly. (I)

I hide my feelings from others.

It is easy for others to tell how I am feeling. (I)

I am very expressive and emotional. (I)

These are items from the self-report version ofthe Inventory ofCallous-Unemotional Traits (ICU). The 3 dimensions emerged fromfactor analyses in nonreferred German and Greek Cypriot adolescentsand detained adolescents in the United States.

I = inversely scored items.

" Items from the original CU scale of the Antisocial Process ScreeningDevice from which items on the ICU were deveioped.

construct similarly across this extended developmentalperiod.

However, the most data are available to address the third ques-tion related to the degree of stability in CU traits. There arenow numerous studies showing that these traits are relativelystable from late childhood to early adolescence, both whenassessed by self-report̂ "* or by parent report."'" For example,in a high-risk sample of children (mean age 10.65 years at ini-tial assessment), the stability of parent ratings of CU traits wasestimated at 0.71 across 4 years, using an ICC as the stabilityestimate." This level of stability for parent report is much

higher than is typically reported for parent ratings of otheraspects of children's adjustment.'^ As a second example ofthis level of stability, the stability of parent ratings of CUtraits across a 9-year period from ages 8 to 16 years in a sam-ple of inner-city boys was r = 0.50." Importantly, the stabil-ity of teacher ratings was significantly lower (r = 0.27) in thissample.

Thus, across childhood and adolescence, CU traits show lev-els of stability that are comparable to or exceed other forms ofchildhood psychopathology. There are also studies to sup-port the stability of these traits into adulthood. CU traits wererelatively stable (r = 0.60) from late adolescence (age 17years) into early adulthood (age 24 years)" and relatively sta-ble (ICC = 0.40) over 6 years, from ages 16 to 18 years, toages 22 to 24 years.^^ Further, 2 studies have shown that mea-sures of CU traits assessed in childhood are significantlyassociated with measures of psychopathy in adulthood, evencontrolling for childhood conduct problems and other riskfactors for antisocial behaviour.'^'*" Importantly, in one ofthese studies,^" the 11 -year stability (from age 13 to 24 years)of CU traits in childhood to an adult measure of psychopathywas r = 0.31. This study also reported that only 21% oftheboys who scored in the upper 10% on the measure of CUtraits at age 13 years were elevated on measures of psychopa-thy at age 24 years. These stability estimates provide animportant context for interpreting the stability of CU traitsfrom childhood into adulthood. On the one hand, these stabil-ity estimates suggest that these traits are not immutable, and alarge number of youth high on these traits are likely to showdecreases in their rate across development. On the otherhand, these traits are as stable or more so than other personal-ity dimensions from childhood to adulthood.''' Further,although most people in the upper 10% of CU traits at age 13years did not show elevated scores as adults, they were still3.22 times more likely to show elevations, compared withthose scoring lower on CU traits in childhood. Thus showingthat high rates of CU traits in childhood does convey somerisk for showing significant levels of psychopathic traits as anadult.

Clinical ImportanceAs noted previously, a critical feature of psychopathic traitsin adults is their ability to designate a more severe, aggres-sive, and chronic pattern of antisocial behaviour. There isevidence to suggest that this may also be true for CU traits inchildhood and adolescence. Specifically, several recent qual-itative"'''" and quantitative"'^^ reviews have been publishedshowing that CU traits, either alone or in combination withother dimensions of psychopathy, are predictive of a moresevere, stable, and aggressive pattern of behaviour in antiso-cial youth. For example, Frick and Dickens"' reported on aqualitative review of 24 published studies using 22

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independent samples. Ten of these studies showed a concur-rent association between CU traits and measures of aggres-sive, antisocial, or delinquent behaviour, and 14 studiesshowed a predictive relation with follow-up intervals rangingfrom 6 months to 10 years. These authors further reported on 5studies showing that CU traits were associated with poorertreatment outcomes. Importantly, these studies included com-munity (n = 6), clinic-referred (« = 4), and forensic (n = 13)samples, and they included samples ranging in age from 4 to20 years. Finally, Frick and White'" reviewed 8 additionalconcurrent studies published after the previous review and 3additional longitudinal studies showing an associationbetween CU traits and the severity of antisocial behaviour.

Thus there is quite a compelling body of research to suggestthat CU traits designate a clinically important group of chil-dren and adolescents with conduct problems. There are sev-eral important issues in interpreting this body of research andfor comparing the use of CU traits to other typologies thathave been proposed to designate developmental precursors topsychopathy. First, CU traits predict more severe behaviourproblems within préadolescent children, even when control-ling for their level of conduct problem behaviours,^' suggest-ing that these traits add predictive utility to a childhood onsetof conduct problems. Second, the association between CUtraits and a more severe pattern of behaviour carmot beaccounted for by higher levels of impulsivity^^ or diagnoses ofADHD.'''' Third, children and adolescents with CU traits notonly show a more severe and pervasive pattern of aggressivebehaviour but also tend to show aggression that is both reac-tive and instrumental. In contrast, youth without CU traitstend to show less aggression overall and, when they do showaggressive behaviour, it tends to be largely reactive innature.^'''''' Thus CU traits account for the patterns of aggres-sion that have been used to designate distinct subgroups ofyouth with conduct problems.

Distinct Correlates in Children and Adolescents With CUTraitsFrick and White^" also reviewed a significant body of researchdemonstrating several differences in the social, cognitive,emotional, and personality characteristics of antisocial youthwith and without CU traits. First, they reviewed 4 studiesshowing that the conduct problems of children or adolescentswithout CU traits are more strongly related to dysfunctionalparenting practices. Second, Frick and White reviewed 10studies showing differences in how antisocial youth with andwithout CU traits process emotional stimuli, with youth highon CU traits showing deficits in the processing of negativeemotional stimuli and, even more specifically, showing defi-cits to signs of fear and distress in others. Third, they reviewedanother 10 studies showing several distinct cognitive charac-teristics of antisocial youth with CU traits, such as being less

sensitive to punishment cues (especially when a rewardoriented response set is primed), showing more positive out-come expectancies in aggressive situations with peers, andbeing less likely to exhibit verbal deficits than other antiso-cial youth. Fourth, they reviewed 7 studies showing that anti-social children and adolescents with CU traits have uniquepersonality characteristics, such as showing more fearless orthrill-seeking behaviours and less trait anxiety orneuroticism, compared with antisocial youth without thesetraits.

Other research has demonstrated important differences in thegenetic contribution to conduct problems for children withand without CU traits. For example, in a large sample of twinsaged 7 years, conduct problems in children with CU traitswere found to be under strong genetic influence (heritabilityof 0.81) with little infiuence of shared environment.^' In con-trast, antisocial behaviour in children without elevated levelsof CU showed a more modest genetic influence (heritabilityof 0.30) and substantial environmental infiuence (sharedenvironmental infiuence = 0.34, nonshared environmentalinfiuence = 0.26). Importantly, the differences in heritabilitycould not be attributed to differences in the severity of con-duct problems in this sample of twins aged 7 years. Finally,these findings were replicated when the children were aged 9years, and this latter study also demonstrated that the differ-ence in heritability remained even after impulsivity-hyperactivity scores were controlled.**"

Unfortunately, these studies do not indicate what biologicalmechanisms may account for the genetic risk in children withCU traits. However, one contemporary theory that accountsboth for the higher genetic risk and for some of the emotionalcharacteristics of youth with CU traits (for example, the defi-cit in response to others' distress) suggests that youth withCU traits may show deficits in the functioning of theamygdala.* In support of this possibility, 2 studies used ameasure that included CU traits and explicitly tested thehypothesis that children with these traits would showamygdalahyporeactivity to others' distress.''̂ "''̂ Both studiesemployed an implicit emotion-processing task (gender rec-ognition) and found amygdala hyporeactivity to fearful facesin antisocial youth with CU traits. Thus, although much morework on the neurological correlates of CU traits is needed,these initial findings from brain imaging studies are promis-ing in uncovering possible neurological bases to some of thecognitive and affective deficits found in this subgroup ofantisocial youth.

CU Traits and Other Dimensions of Psychopathy

Based on this research, it seems clear that the presence orabsence of CU traits designates an important subgroup ofantisocial children and adolescents. However, as noted

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previously, these traits are only one of several personalitydimensions that have been used to define psychopathy. Othermodels that have attempted to extend the construet of psy-chopathy to youth have emphasized other dimensions, such aselevations on impulsivity and antisocial behaviour"'^'* or haveconceptualized psychopathy as involving high scores on all 3component personality dimensions (that is, CU traits, narcis-sism, and impulsivity), as well as antisocial behaviour.^' Insupport of the latter definition of psychopathy, all 4 facets ofthe construct seem to be important for predicting the severityand chronicity of antisocial behaviour and, as a result, com-bining them often provides the best method of predictingfuture antisocial behaviour in samples of youth.^" However,the model focusing on CU traits also has several positive fea-tures for developmental models of psychopathy.

Specifically, the CU dimension shows the least amount ofoverlap with traditional definitions of conduct problems andantisocial behaviour in samples of children and adolescents.'*^Further, and likely owing to this lower overlap, the CU dimen-sion, but not the other dimensions of psychopathy, consis-tently designates an important subgroup within antisocialyouth. For example, within a sample of adjudicated adoles-cents, narcissistic and impulsive traits did not differentiateamong nonviolent offenders, violent offenders, and violentsex offenders, whereas violent sex offenders exhibited higherlevels of CU traits.'" Similarly, a cluster analysis of the dimen-sions of psyehopathy and conduct problems in aclinic-referred sample of children revealed 2 distinct clustersof children with childhood-onset conduct problems.*"* Bothgroups were diagnostically similar in their rates of ADHD andconduct problem diagnoses. Although the groups did not dif-fer on their level of impulsivity and narcissism, one groupshowed higher levels of CU traits and this group showed moresevere conduct problems and had higher rates of policecontact.

Importantly, because children and adolescents with CU traitsoften show the highest rates of impulsivity, narcissism, andantisocial behaviour, using high scores on CU traits and usingcomposite scores on all dimensions of psychopathy often des-ignate very similar groups of youth.'*'' However, CU traitsseem to be more specifically related to many of the uniqueemotional, cognitive, and social characteristics that werereviewed previously. For example, as noted previously, thehigher level of heritability of antisocial behaviour in youthwith CU traits could not be accounted for by higher levels ofimpulsivity.*"* Similarly, the reduced reactivity to negativeemotional stimuli in some antisocial youth has been specifi-cally related to high levels of CU traits but not to elevated lev-els of impulsivity and narcissism.^' As a final example, thedifferential association between dysfunctional parenting andconduct problems in those high and low on CU traits was not

found for the other dimensions of psychopathy.'^ Thus CUtraits seem to be especially important for designating aunique subgroup of antisocial youth who show many featuresconsistent with the construct of psyehopathy.

Concerns About Extending the Construct toYouthBefore discussing some of the implications of this researchon CU traits in children and adolescents, it is important tonote some concerns that have been expressed about attemptsto extend the construct of psychopathy to youth. Some con-cerns are not about the construct of psychopathy itself butfocus instead on potential misuses of it, such as the use of theconstruct to support transferring youth who commit seriouscrimes to adult court.'^ Other concerns are not specific to psy-chopathy but are issues that are relevant to all forms of child-hood psychopathology, such as the fact that some level ofsymptomatology is present in normally developing youth.'"*

However, there are some concerns that are specific to theconstruct of psychopathy. Most important, the term psychop-athy cormotes a stable and untreatable dispositional ten-dency.'^ The appropriateness of this assumption isquestionable, even in adults.'* However, it is even more ques-tionable in children, for whom there is clear evidence that thefeatures can change across development.'^'*" Also, it isimportant to note that research suggests that the term psy-chopathy may not have any more negative or stigmatizingconnotations than the terms CD or antisocial behaviour." Infact, one problem in not recognizing that only a small per-centage of antisocial youth or youth with CD show character-istics associated with psychopathy is that these terms canbecome viewed as interchangeable. Given our focus on onlyone dimension related to psychopathy, we have chosen to usethe purely descriptive term CU traits in research. While sucha term still does not denote characteristics that would besocially desirable, it is important to maintain clarity as to thecore features of the construct being assessed. That is, earlyattempts to operationalize psychopathic traits in youth werehindered when the name was changed to undersocializedaggression in an attempt to use a less pejorative label.'*Unfortunately, this led to attempts to defineundersocialization that bore no resemblance to the core affec-tive and interpersonal features of psychopathy."

Implications for Causal Theories of Antisocialand Aggressive BehaviourImportantly, there are numerous theoretical implications ofthis research on CU traits. For example, this research clearlysuggests that there are several distinct developmental path-ways through which children and adolescents may developsevere antisocial and aggressive behaviour.'" Specifically, in

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addition to the distinction that is often made between adoles-cent- and childhood-onset antisocial behaviour, it appears thatthe presence or absence of CU traits is also important forcausal theories. Youth with CU traits appear to show a distincttemperamental style that is characterized by a lack ofresponsivity to negative stimuli (especially distress in others),abnormalities in responsivity to rewards and punishment, anda preference for novel and dangerous activities.'" Such a tem-peramental style can influence the child's development ofappropriate levels of guilt and empathy by making the childless sensitive to the effects of their behaviour on others^" or byleading the child to be less responsive to typical (although notall) parental socialization practices.^' In outlining such adevelopmental pathway, it is important to recognize that sucha trajectory is not immutable, and some children with this tem-peramental style may develop appropriate levels of guilt andempathy, if they experience certain corrective environments.For example, in a study of 87 preschool children selectedaccording to their temperaments, those with a temperamentalstyle that placed them at risk for problems in the developmentof empathy and guilt showed normal levels of conscience, ifthey experienced consistent and strong, rule-orientedparenting.82

In contrast, youth with a childhood-onset of antisocial behav-iour but without CU traits appear to be distressed by theeffects of their behaviour on others and they seem to showpoorly regulated emotions that lead to high levels of anger andirritability. ' ̂ Also, such children are more likely to show defi-cits in verbal intelligence and other problems in executiveñinctioning that can lead to problems anticipating the conse-quences of their behaviour.'"''^ These dispositional vulnera-bilities likely interact with problematic rearing environmentsthat lead to failures in the child's ability to develop appropri-ate emotional and behavioural regulation strategies.

Thus the presence or absence of CU traits seems to be criticalfor designating important pathways in the development ofsevere antisocial behaviour. In addition to these importanttheoretical implications, this body of research points the wayto several potentially important directions for future research.For example, a key aspect to the developmental models out-lined in this manuscript is the different temperaments that mayplace a child at risk for showing severe antisocial and aggres-sive behaviour. However, the vast majority of research hasfocused on children and adolescents who already show prob-lem behaviour. As a result, it will be critical for future researchto study children with the hypothesized temperamental riskfactors (for example, low levels of fearful inhibitions) early inlife to determine how well they predict later CU traits andsevere antisocial behaviour. Such prospective research is notonly important for providing strong tests of the predictiveclinical utility of the developmental model but also could help

to uncover protective factors that may reduce the likelihoodthat a child with a temperamental risk factor will show severebehaviour problems.

Implications for Assessment and DiagnosisBecause of these different developmental pathways to antiso-cial and aggressive behaviour, it is important that clinicalevaluations use assessment procedures that can help to deter-mine which of these pathways best describes a child who isdisplaying antisocial and aggressive behaviour.^' For exam-ple, if a child's serious conduct problems began prior to ado-lescence but he or she does not show significant levels of CUtraits, a typical profile would include the presence of verbaldeficits and temperamental vulnerabilities involving prob-lems regulating emotions, leading to higher levels of anxiety,depression, and anger. In contrast, for a child with childhood-onset antisocial behaviour who shows high levels of CUtraits, the child is more likely to show a lack of sensitivity topunishment, a preference for dangerous and novel activities,and a failure to experience many types of prosocial emotions(for example, guilt and empathy). Further, assessing the leveland severity of aggressive behaviour, especially the presenceof instrumental aggression, would be critical for this child.As most clinicians recognize, people often do not fall neatlyinto the prototypes that are suggested by research. Therefore,these descriptions are meant to serve as hypotheses aroundwhich to organize an evidence-based assessment. They alsocan be used to highlight several important pieces of informa-tion that are needed when assessing children and adolescentswith serious antisocial and aggressive behaviour, such as theage at which the serious conduct problems began and thepresence of CU traits (see McMahon and Frick*" for adescription of specific assessment methods).

To promote such assessment practices, it is critical that theimportance of CU traits for designating a distinct group ofantisocial youth be recognized in diagnostic criteria. Unfor-tunately, much of the research to date on CU traits has useddimensional scales that make it hard to translate the findingsinto specific diagnostic criteria. However, the research todate does suggest that the diagnostic criteria, such as those forCD,' would be enhanced by including some method for des-ignating youth with this disorder who display significant lev-els of CU traits.

Implications for TreatmentPerhaps the most important implications from this researchon antisocial youth with CU traits are those related to inter-vention. First, given that children with CU traits start to showconduct problems early in their development'" and there arenumerous interventions that have proven effective in treatingearly emerging conduct problems,*^ intervening early in the

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In Review

developmental trajectory of childhood-onset conduct prob-lems is an important goal for preventing later serious aggres-sion and antisocial behaviour. Second, in older children withsevere antisocial behaviours, the most successful interven-tions are comprehensive interventions that are tailored to theunique needs of the individual child.*^ Thus research on thedifferent developmental pathways to conduct problems couldhelp to guide these individualized interventions. For example,interventions that focus on anger control may be more effec-tive for children within the childhood-onset pathway who donot exhibit CU traits but who often show problems with emo-tional regulation. In contrast, treatments that intervene early inthe parent-child relationship to teach parents ways to fosterempathie concern in their young child or that help the childdevelop cognitive perspective-taking skills may be moreeffective for children with CU traits. Later in development,intervening in ways that emphasize the reward-orientedresponse style of this group and attempt to motivate childrenthrough appealing to their self-interest, rather than throughinterventions that solely focus on punishment-oriented strate-gies, may be more effective for this group.'"

Unfortunately, much of the existing research has largelyfocused on demonstrating that youth with CU traits often doless well in existing treatment programs than other antisocialchildren and adolescents. However, 2 studies have providedsome important information on strategies that might be effec-tive for children with CU traits. First, Hawes and Dadds*'reported that clinic-referred boys (aged 4 to 9 years) with con-duct problems and CU traits were less responsive to aparenting intervention than boys with conduct problems butwho were low on CU traits. However, this differential effec-tiveness was not consistently found across all phases of thetreatment. That is, children with and without CU traits seemedto respond equally well to the first part of the intervention thatfocused on teaching parents methods of using positive rein-forcement to encourage prosocial behaviour. In contrast, onlythe group without CU traits showed added improvement withthe second part of the intervention that focused on teachingparents more effective discipline strategies. This outcomewould be consistent with the reduced sensitivity to punish-ment that is often characteristic of children with CU traits. In asecond study, Waschbusch et al*̂ reported that children (aged7 to 12 years) with conduct problems and CU traits respondedless well to behaviour therapy alone than children with con-duct problems without CU traits. However, these differenceslargely disappeared when stimulant medication was added tothe behaviour therapy, although the children with CU traitswere still less likely to score in the normative range than thosewithout these traits.

Thus direct tests of differential treatment effects for childrenwith CU traits are few, but those that have been conducted

suggest that typical interventions may be less effective forthis group of antisocial youth. However, the availableresearch also provides at least suggestive evidence to refutethe contention that these youth are untreatable. Instead, theyprovide very intriguing data to suggest that interventionsbased on our knowledge of the distinct characteristics of thisgroup could enhance the effectiveness of treatments for chil-dren and adolescents with CU traits who show very severebehaviour problems. Further, they provide very compellingreasons for advancing this line of work to better renne ourknowledge of this clinically important subgroup of antisocialyouth to guide future advances in prevention and treatment.

Funding and SupportThe Canadian Psychiatric Association proudly supports the InReview series by providing an honorarium to the authors.

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Manuscript received April 2009, revised, and accepted May 2009.'Professor, Director of Applied Developtnental Psychology Program,Department of Psychology, University of New Orleans, New Orleans,Louisiana; Research Professor, Chair, Department of Psychology,University of New Orleans, New Orleans, Louisiana.Address for correspondence: Dr PJ Frick, Department of Psychology,University of New Orleans, 2001 Geology and Psychology Building,New Orleans, LA 70148; pfrick@uno.edu

Résumé : Étendre le construit de la psychopathie aux jeunes : implications pourcomprendre, diagnostiquer et traiter les enfants et adolescents antisociauxCet article examine plusieurs tentatives d'étendre le construit de la psychopathie aux enfants et auxadolescents. La recherche suggère que la présence de traits de dureté-insensibilité (DI) peut êtreparticulièrement importante. Spécifiquement, la présence de ces traits désigne un sous-groupecliniquement important déjeunes ayant des problèmes de conduite apparus dans l'enfance quidémontrent un modèle stable de comportement antisocial très grave et agressif De même, lesenfants ayant des traits DI présentent de nombreuses caractéristiques émotionnelles, cognitives et dela personnalité qui sont distinctes d'autres jeunes antisociaux et qui sont semblables auxcaractéristiques observées chez les adultes atteints de psychopathie. La recherche sur les traits DI ad'importantes implications pour comprendre les différentes voies causales par lesquelles les enfantsdéveloppent un comportement antisocial grave et agressif, ainsi que des implications pourdiagnostiquer les jeunes antisociaux et intervenir auprès d'eux.

812 La Revue canadienne de psychiatrie, vol 54, no 12, décembre 2009

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