Conduct problems (CP) refer to a clinical diagnosis, characterised by a repetitive and severe pattern of rule-breaking behaviours that violates the basic rights of others (Frick, 2012). Such disruptive behaviours exhibited in children and adolescents are considered as a precursor of significant behavioural, social and emotional impairments in adulthood (Kim-Cohen et al. , 2009). Even though many children diagnosed with CP desist from antisocial behaviours, one-third of the treated children show poor treatment response and continue to commit criminal offences as they reach adulthood (Rowe et al. , 2010), suggesting that there are dispositional factors uniquely associated with the persistence of CP (Pardini, Byrd, Hawes, & Docherty, 2018).
The co-existence of Callous-Unemotional (CU) traits in children with CP has been found to be associated with not only the poor treatment outcome but also the severity and stability of antisocial behaviours (Fanti, 2013; Frick, Ray, Thornton, & Kahn, 2014). The term “CU traits” refers to a lack of empathy, reduced remorse and limited prosocial emotions (Blair, Leibenluft, & Pine, 2014). CP, in the presence of CU traits predicts many consequential outcomes, including aggression (Marsee, Silverthorn, & Frick, 2005); sex offending (Lawing, Frick, & Cruise, 2010); violent behaviour and poorer adjustment in juvenile institutions (Frick, 2012). Based on this line of research, CU traits have been added to the definition of conduct disorder in the DSM V as a “limited prosocial emotions” specifier to describe a subgroup of children with conduct disorder and co-occurring CU traits (American Psychiatric Association, 2013). It is important to identify the characteristics of this subgroup to predict its concurrent and future impairments for the purpose of research and clinical practice (Moffitt et al. , 2008). Twin studies investigating the differences between children who have CP with and without co-occurring CU traits show that these two groups have distinct etiological pathways (Hyde, Shaw, & Hariri, 2013). Individual differences in CU traits have been found to be significantly heritable even when CU traits occur in the absence of CP, reflecting a strong genetic influence in this subgroup (Larsson, Viding, Rijsdijk, & Plomin, 2007).
A study on antisocial behaviour in 9 year-old children indicates genetic variability is responsible for 71% of the variance in children with high CU traits as opposed to 36% of those in children with low CU traits (Viding, Jones, Paul, Moffitt, & Plomin, 2008). Despite the genetic vulnerability, researchers believe high heritability does not necessarily imply the behaviour remains unchanged across time (Viding et al. , 2008). More importantly, there is no single gene responsible for CU traits but rather a combination of many genes that confers either advantages or disadvantages, depending on its interaction with the environment (Hyde et al. , 2016). The heritable pathway alone cannot explain the manifestation of CP however, its interaction with the environment does help shed light on the disorder (Hyde at al. , 2016). Jaffee et al. (2005) found that the probability of maltreated children developing CP is increased by 24% if they also carry high genetic risk, compared to 2% in those with low genetic risk. One possible explanation is children who experience abuse at such early ages normalise violent behaviours and become desensitised to violence, which in turn cause disruptions to the typical development of guilt and remorse (Docherty, Kubik, Herrera, & Boxer, 2018). In a hostile situation, these individuals are more likely to resort to aggressive behaviours than those who have learned the appropriate coping strategies in a caring environment (Boxer & Sloan-Power, 2013). These findings indicate the interaction of genetic vulnerability and environmental factors predisposes youth to antisocial behaviour.
In addition, Bowlby’s (1982) attachment theory proposes that early disrupted attachment relationships are critical in delineating the affectionless traits in children. This theory is supported by several studies as evident from the results, adolescents who experienced early institutional deprivation show significant levels of emotional dysfunctions (Kennedy et al. , 2016); and children with attachment problems at age 4 exhibit shallow emotions and uncaring behaviours at age 15 (Sonuga-Barke, Schlotz, & Kreppner, 2010). Hence, attachment should be considered as an important environmental predisposing factor for the prognosis of children with CU traits. One of the main issues with CP diagnosis is the strong focus on the behavioural components without taking into account the emotional symptoms (Blair, Peschardt, Budhani, Mitchell, & Pine, 2006). Various studies have found that, in threatening situations, many children with CP exhibit heightened levels of anxiety and distress while some others are not reactive to those emotionally distressing stimuli (Loney, Frick, Clements, Ellis, & Kerlin, 2003). The reduction of emotional reactivity has been linked to high levels of CU traits (Loney et al. 2013). Children of this subgroup show brain reactivity deficits and reduced amygdala activity whereas those with low CU traits show exaggerated amygdala activity in response to fearful faces (Sebastian et al. , 2012). Skin conductance reactivity and heart rate in response to other’s distress are also lower in children with high CU traits than those with low CU traits (Wied, Boxtel, Matthys, & Meeus, 2011).
Interestingly, infants who have fearless temperament at age 2 are more likely to have CU traits at age 13 despite the control of parenting variables (Barker, Oliver, Viding, Salekin, & Maughan, 2011). This could be used as a plausible explanation for why traditional discipline strategies are not effective in children with CP and elevated CU traits, which is due to the characteristic insensitivity towards reinforcement information, especially punishment cues (Frick et al. , 2014). Time out and punitive interactions fail to trigger emotional responses such as guilt or distress in the child, causing the violent behaviours to be persistently maintained (Frick et al. , 2014). Also, there is growing evidence that the ability to show empathy for others emerges by the age of 3 and moral development occurs prior to the age of 6 (Decety & Svetlova, 2012), suggesting early intervention is very important in helping children with CP and CU traits to readjust their moral beliefs and emotion recognition (Datyner, Kimonis, Hunt, & Armstrong, 2015).
These findings demonstrate the population of children with CP is heterogenous in nature (Blair et al. , 2006), and the level of emotional reactivity could be considered as a unique factor that allows researchers to gain insight into the development of instrumental antisocial behaviour. Even though many social and familial approaches help reduce symptoms of CP, the treatment progress is refractory in severe behavioural disorders, especially those with high levels of CU traits show lower quality of treatment participation, high resistance and poorer response to discipline strategies compared to those with low levels of CU traits (Frick et al. , 2014). Parenting styles critically contribute to the development and maintenance of CP (Kimonis, Bagner, Linares, Blake, & Rodriguez, 2013). Negative parenting has been found to be correlated with high CU trait compared to warm parenting, however, the direction of this correlation is unclear as it is possible that negative parenting exacerbated the severity of CU traits or, CU traits evoked negative parenting (Waller, Gardner, & Hyde, 2013). To eliminate the passive gene-environment association, adoption design was implemented. Adoptive parents who used positive reinforcement on children with CP and CU traits alleviated the effects of heritable risk on CU behaviours, illustrating that positive reinforcement was important in parenting practices for this particular group (Hyde et al. , 2016).
Furthermore, previous studies have shown that children with high CU traits have problems with fear recognition due to a lack of attention to other people’s eyes, resulting from neural abnormalities in the amygdala (Dadds et al. , 2006). Based on these findings, researchers conducted emotional recognition training (ERT) that not only taught children to perceive and interpret human emotions correctly but also established effective parent-child interaction (Dadds, Cauchi, Wimalaweera, Hawes, & Brennan, 2012). Children scoring high on CU traits demonstrated significant improvements in affective sympathy and CP following ERT (Dadds et al. , 2012). These outcomes suggest it is possible to modify CU traits in children through shifting their attentional focus and that emotional impairments are not immutable. Emerging evidence also points out that some children who are high on CU traits do not display any symptoms of CP (Fanti, 2013; Rowe et al. , 2010). These children demonstrate superior executive functioning which helps them monitor and inhibit the behaviours that are more likely to create negative consequences (Sellbom & Verona, 2007).
They also have lower levels of hyperactivity and impulsivity than those who have CP and co-occurring CU traits, suggesting that the inhibition of antisocial behaviour is associated with impulse control (Fanti, 2013; Rowe et al. , 2010). On a social level, researchers have found that these children are more connected with school than those with heightened CP and CU traits (Wall, Frick, Fanti, Kimonis, & Lordos, 2016). This provides insight into school-connectedness as a promising factor for treatment and intervention strategies of severe behavioural problems. Although it is unclear whether these individuals will exhibit antisocial behaviour or any psychopathology in the future, understanding the underlying biological and behavioural mechanisms that inhibit them from harming and violating the rights of others despite a lack of prosocial emotions is necessary. In criminal history, many notorious serial killers have exhibited a pervasive pattern of psychopathy, characterised by a profound lack of remorse towards immoral actions and severe antisocial behaviour in adulthood (Murrie, Boccaccini, Mccoy, & Cornell, 2007). Even though CU traits in children share common features with adult psychopathy and are often considered as psychopathy’s precursor, it is quite controversial to label a child with psychopathy (Viding & Mccrory, 2017).
Firstly, many transient developmental attributes could be mistakenly labelled as psychopathic attributes as not all children who show early behavioural problems develop antisocial behaviour and shallow affect in adulthood (Seagrave & Grisso, 2002). Secondly, the terms “antisocial behaviour” and “psychopathy” are often used interchangeably in the news and media while in fact, only a small number of children with antisocial behaviour continue to develop psychopathy in adulthood. Thirdly, the negative connotations of “CU traits” or “antisocial behaviour” have been found to be highly stigmatised, which create punitive consequences on forensic evaluations by clinicians and legal decisions by the judges (Murrie et al. , 2007).
A study by Edens, Colwell, Desforges, & Fernandez (2005) has found that 60% of participants supported the death penalty for psychopathic defendants while only 30% of participants thought that defendants with other diagnostic conditions were more deserving of death, suggesting the lack of clarity when conceptualising those terms could result in misdiagnosis and biased crime sentences. Over the past decades, much research has been devoted to further understand the complexity of CP. Children with CP and co-occurring CU traits display a more severe pattern of antisocial behaviour and produce a much poorer treatment outcome, especially when the problematic behaviours start before the age of 10 years (Kyranides, Fanti, Katsimicha, & Georgiou, 2017). Those that continue to manifest violent and rule-breaking behaviours in adulthood also incur significant societal burden, individual costs and psychological consequences to the victims (Murrie et al. , 2007).
The uniqueness of this subgroup indicates a distinct treatment approach and requires intensive interventions in various settings (Hawes & Dadds, 2005). Intervention strategies should place a strong focus on positive parenting styles, school-based prevention and child-focus to achieve improvements in the child’s behaviour. Moreover, the current treatments show a reduction in CP, yet the efficacy is moderate as it only targets the behavioural symptoms on the surface (Blair et al. , 2014). It is critical to deconstruct the underlying issues of disruptive behavioural disorders not only at clinical level where the primary focus is individual behaviour but also at neurobiological level where the brain mechanisms and neural circuits can be understood.
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