Callous unemotional traits in children with disruptive behavior disorder: Predictors of developmental trajectories and adolescent outcomes
Introduction
Disruptive Behavior Disorders (DBDs), including Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), are serious mental disorders associated with a host of social, emotional, and behavioral problems, both current and later emerging, with high costs for the community (Kolko et al., 2009). In order to reduce the apparent heterogeneity of DBDs, psychopathic traits have been proposed as a relevant factor in subtyping conduct problems (White and Frick, 2010). The conceptualization of psychopathic traits in children typically focuses on the presence of Callous-Unemotional (CU) traits: lack of empathy and guilt, constricted affects, deceitfulness, shallow and deficient emotions (American Psychiatric Association, 2013).
Previous longitudinal studies showed that CU traits in childhood were concurrently and prospectively associated with severe conduct problems (Lynam et al., 2009, Lopez-Romero et al., 2012), and lower levels of pro-social behavior, social competence skills and emotional regulation (Viding et al., 2009, Masi et al., 2015). In addition, poorer adolescence outcomes for children with high CU traits have been reported not only in children with DBDs, but also in community samples (for a review see Frick et al. (2014)).
Although elevated levels of CU symptoms are associated with future antisocial behavior, not all youths with these symptoms in childhood continue to show them into adolescence. For this reason, several studies have examined the stability of CU traits across childhood or from childhood to early adolescence (Frick et al., 2003, Dadds et al., 2005, Obradivic et al., 2007, Fontaine et al., 2010, Fontaine et al., 2011). For instance, Fontaine et al. (2010) found that a small proportion of children have unstable levels of CU traits over time, although elevated levels of CU traits (even if unstable) represent a relevant marker for risk of adjustment problems in early adolescence.
All these previous studies focused primarily on normative or at-risk samples; specifically, no studies examined in a clinical sample the association between CU traits in childhood and later outcomes using a growth curve analysis. In the current study, we used the growth curve modeling to explore the trajectories of CU traits from childhood to adolescence in a clinical sample. Moreover, individual differences in growth trajectories can predict dysfunctional adolescent outcomes, and early environmental and clinical factors can predict individual differences in CU traits growth trajectories over time. In our opinion, understanding whether CU traits trajectories could be influenced by environmental and/or clinical variables may be relevant to identify possible treatment targets.
A number of variables emerged from previous studies as risk or protective factors for high and stable levels of CU traits during childhood, both child and environmental related. Among the former, genetic and temperamental variables, early-onset conduct problems and hyperactivity comorbidity have been reported as mostly influential; regarding environmental variables, low family's socio-economic status is the most important predictor of high CU traits (Viding et al., 2005, Fontaine et al., 2011). Further, growing evidence indicates that parenting practices may also influence the maintenance of CU traits in children over time. Although harsh and coercive discipline has been associated with conduct problems in youths with normal levels of CU traits (Pasalich et al., 2011), some studies suggest that these dysfunctional parenting practices may affect CU traits themselves (Barker et al., 2011). However, (Viding et al., 2009) showed that during the transition to early adolescence, negative parental discipline operates as a non-shared environmental risk factor for development of conduct problems, but not for the development of CU traits. Previous studies suggested also that high parental involvement is associated to a decrease in CU traits over time (Pardini et al., 2007), whereas parental monitoring may be the most relevant dimension of parenting in the adolescence period (Munoz et al., 2011).
The present study aims to explore growth trajectories of CU traits in a sample of children with DBD diagnosis referred to a mental health service. The trajectories of CU features were investigated in children followed-up from childhood to adolescence (ages 08–09 to 14–15 years), using a growth curve analysis. We firstly investigated the growth curve of CU traits and inter-individual variability. Secondly, we explored the role of several predictors of these trajectories, including socio-economic and parenting variables, baseline diagnosis (ODD or CD), comorbidity (ADHD and Mood Disorder-MD), general functioning, and additional pharmacological treatment. Finally, we included in the model clinical outcomes in adolescence. Overall, we hypothesized that a slower decrease of CU traits during childhood is associated to a higher risk for poorer clinical outcomes into adolescence (severe aggression and antisocial behaviors in early adolescence, such as externalizing symptoms, substance use and CD diagnosis).
Section snippets
Participants and procedure
A sample of children firstly referred for behavioral problems to a pediatric psychiatric hospital and received a systematic evaluation. Trained child psychiatrists administered separately to parents and youths a diagnostic clinical interview, the Schedule for Affective Disorders and Schizophrenia for School- Age Children- Present and Lifetime Version (K-SADS-PL) (Kaufman et al., 1997). Cognitive abilities in all the participants were assessed with the Wechsler Intelligence Scales for Children –
Unconditional latent growth curve
The first model tested was a linear model representing a constant change over time: to define the linear metric of time, the factor loadings for the slope were set to 0, 1, 2 and 4. The model did not fit the data well (χ2⌷(05)=13.977; p=.016; RMSEA=.177; CFI=.800). The second model tested was a quadratic model. The model fit the data well (χ2 (01)=.335; p=.050; RMSEA=.000; CFI=1.00). However, given that the model showed a non–significant variance of the quadratic slope, and considering the
Discussion
The results from the current investigation provide significant insights into the developmental trajectories of CU traits during childhood in patients with DBD diagnosis referred to a mental health service for receiving a treatment. Children's levels of CU traits decreased during the treatment period, and this decrease continued during years thereafter; on the contrary, when patients became adolescents (from 12 to 15 years), the CU traits showed a decelerated decrease with a substantial
Financial support
None.
Conflict of interest
Dr. Masi was in the advisory boards for Eli Lilly, Shire and Angelini, has received research grants from Eli Lilly and Shire, and has been speaker for Eli Lilly, Shire, Lundbeck, and Otsuka. All the other authors do not have conflicts of interest to declare.
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