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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
The Canadian Journal of Psychiatry, Voi 54, No 12, December 2009
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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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Extending the Construct of Psychopathy to Youth: Implications
for Understanding, Diagnosing, and Treating Antisocial Children and
Adolescents
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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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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Extending the Construct of Psychopathy to Youth: Implications
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Adolescents
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
The Canadian Journal of Psychiatry, Vol 54, No 12, December 2009
809
-
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; [email protected]
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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