Evaluation of Improvement in Externalizing Behaviors and Callous-Unemotional Traits in Children with Disruptive Behavior Disorder: A 1-Year Follow Up Clinic-Based Study

Investigating the Trajectory and Associated Risk Factors of Clinical Outcomes for Early Childhood Disruptive Behavior Disorders Using Real World Data

Disruptive behavior disorders (DBDs) are common mental health problems among early childhood American youth that, if poorly managed, pose costly psychological and societal burdens. There is limited real world evidence on how parent management training (PMT) - the evidence-based treatment model of choice - implemented in common practice settings within the United States influences the behavioral progress of early childhood DBDs, and the risk factors associated with poor outcomes. This study used data from a measurement feedback system implemented within a U.S.-based private practice to study how behavioral outcomes change as a function of PMT treatment engagement and associated risk factors for 4-7 year-old children diagnosed with DBDs. Over 50% of patients reached optimal outcomes after 10 appointments. Attending 24-29 appointments provided maximum treatment effect - namely, 75% of patients reaching optimal outcomes by end of treatment. Outcomes attenuate after reaching the maximum effect. Patients also had higher odds of reaching optimal outcomes if they had consistent attendance throughout the treatment course. Notable risk factors associated with lower odds of reaching optimal outcomes included Medicaid insurance-type, greater clinical complexity, and having siblings concurrently in treatment. Increased implementation of systems that monitor and provide feedback on treatment outcomes in U.S.-based practice settings and similar investigations using its data can further enhance 'real world' management of early childhood DBDs among American youth.

Rapid white matter changes in children with conduct problems during a parenting intervention

Studies report that the microstructural integrity of the uncinate fasciculus (UF; connecting the anterior temporal lobe to the orbitofrontal cortex) is abnormal in adults with psychopathy and children with conduct problems (CP), especially those with high callous-unemotional (CU) traits. However, it is unknown if these abnormalities are 'fixed' or 'reversible'. Therefore, we tested the hypothesis that a reduction in CP symptoms, following a parenting intervention, would be associated with altered microstructural integrity in the UF. Using diffusion tensor imaging tractography we studied microstructural differences (mean diffusivity (MD) and radial diffusivity (RD)) in the UF of 43 typically developing (TD) and 67 boys with CP before and after a 14-week parenting intervention. We also assessed whether clinical response in CP symptoms or CU traits explained changes in microstructure following the intervention. Prior to intervention, measures of MD and RD in the UF were increased in CP compared to TD boys. Following intervention, we found that the CP group had a significant reduction in RD and MD. Further, these microstructural changes were driven by the group of children whose CU traits improved (but not CP symptoms as hypothesized). No significant microstructural changes were observed in the TD group. Our findings suggest, for the first time, that microstructural abnormalities in the brains of children with CP may be reversible following parenting intervention.

Contemporary diagnosis and treatment of conduct disorder in youth

INTRODUCTION

Conduct disorder (CD) is characterized by repetitive and persistent antisocial behaviors, being among the most frequently reported reasons of referral in youth. CD is a highly heterogeneous disorder, with possible specifiers defined according to age at onset, Limited Prosocial Emotions (LPE) otherwise known as Callous-Unemotional (CU) traits, Emotional Dysregulation (ED), and patterns of comorbidity, each with its own specific developmental trajectories.

AREAS COVERED

The authors review the evidence from published literature on the clinical presentations, diagnostic procedures, psychotherapeutic and psychoeducational approaches, and pharmacological interventions from RCT and naturalistic studies in youth. Evidence from studies including youths with LPE/CU traits, ED and aggression are also reviewed, as response moderators.

EXPERT OPINION

Due to its clinical heterogeneity, relevant subtypes of CD should be carefully characterized to gain reliable information on prognosis and treatments. Thus, disentangling this broad category in subtypes is crucial as a first step in diagnosis. Psychosocial interventions are the first option, possibly improving LPE/CU traits and ED, especially if implemented early during development. Instead, limited information, based on low-quality studies, supports pharmacological options. Second-generation antipsychotics, mood stabilizers, and stimulants are first-line medications, according to different target symptoms, such as aggression and emotional reactivity. Developmental pathways including ADHD suggest a specific role of psychostimulants.

Selective Amygdala Hypoactivity to Fear in Boys With Persistent Conduct Problems After Parent Training

BACKGROUND

Parenting interventions reduce antisocial behavior (ASB) in some children with conduct problems (CPs), but not others. Understanding the neural basis for this disparity is important because persistent ASB is associated with lifelong morbidity and places a huge burden on our health and criminal justice systems. One of the most highly replicated neural correlates of ASB is amygdala hypoactivity to another person's fear. We aimed to assess whether amygdala hypoactivity to fear in children with CPs is remediated following reduction in ASB after successful treatment and/or if it is a marker for persistent ASB.

METHODS

We conducted a prospective, case-control study of boys with CPs and typically developing (TD) boys. Both groups (ages 5-10 years) completed 2 magnetic resonance imaging sessions (18 ± 5.8 weeks apart) with ASB assessed at each visit. Participants included boys with CPs following referral to a parenting intervention group and TD boys recruited from the same schools and geographical regions. Final functional magnetic resonance imaging data were available for 36 TD boys and 57 boys with CPs. Boys with CPs were divided into those whose ASB improved (n = 27) or persisted (n = 30) following the intervention. Functional magnetic resonance imaging data assessing fear reactivity were then analyzed using a longitudinal group (TD/improving CPs/persistent CPs) × time point (pre/post) design.

RESULTS

Amygdala hypoactivity to fear was observed only in boys with CPs who had persistent ASB and was absent in those whose ASB improved following intervention.

CONCLUSIONS

Our findings suggest that amygdala hypoactivity to fear is a marker for ASB that is resistant to change following a parenting intervention and a putative target for future treatments.

Equipping Youth to Think and Act Responsibly: The Effectiveness of the “EQUIP for Educators” Program on Youths’ Self-Serving Cognitive Distortions and School Bullying Perpetration

School bullying is a serious public health concern in many countries worldwide. Over recent decades, several effective anti-bullying prevention programs have been developed. This study aimed to evaluate the effectiveness of an adapted version of the “Equipping Youth to Help One Another (EQUIP) for Educators” (EfE) program in reducing adolescents’ engagement in school bullying perpetration by correcting their use of self-serving cognitive distortions (CDs). Furthermore, guided by the vantage sensitivity framework, we investigated whether the intervention effects varied depending on the adolescents’ gender and environmental sensitivity. A quasi-experimental pre-test/post-test with a control group design involved 354 Italian middle and high school adolescents (51.7% males; Mage = 14.86, SD = 2.54). Both the control (n = 187) and experimental group (n = 167) completed self-report questionnaires, before and after the intervention. Structural equation modeling revealed a significant moderated mediation effect: highly sensitive males participating in the EfE program decreased their engagement in bullying by reducing CDs, compared to females and those with low- and medium- sensitivity. These findings support the effectiveness of the EfE program in equipping youth to think and act more responsible and shed light on “why” and “for whom” the intervention might work better to counteract school bullying during adolescence.

Facial Affect Sensitivity Training for Young Children with Emerging CU Traits: An Experimental Therapeutics Approach

OBJECTIVE

This article delineates best practices in the application of the experimental therapeutics framework for evaluating interventions within the context of randomized controlled trials (RCTs), offering a methodological primer and guiding framework for this approach. We illustrate these practices using an ongoing clinical trial conducted within the framework of a National Institute of Mental Health exploratory phased-innovation award for the development of psychosocial therapeutic interventions for mental disorders (R61/R33), describing the implementation of a novel "Facial Affect Sensitivity Training" (FAST) intervention for children with callous-unemotional (CU) traits. CU traits (e.g., lack of guilt or remorse, low empathy, shallow affect) are an established risk factor for persistent and severe youth misconduct, which reflect impairment in identified neurocognitive mechanisms that interfere with child socialization, and predict poor treatment outcomes, even with well-established treatments for disruptive behavior.

METHOD

We outline the stages, goals, and best practices for an experimental therapeutics framework. In the FAST trial, we assert that impaired sensitivity for emotional distress cues (fear and/or sadness) is mechanistically linked to CU traits in children, and that by targeting sensitivity to facial affect directly via a computerized automated feedback and incentive system, we can exert downstream effects on CU traits.

RESULTS

In the context of an open pilot trial, we found preliminary support for feasibility and mechanism engagement using FAST.

CONCLUSIONS

We summarize pilot study limitations and how they are being addressed in the R61/R33 RCTs, as well as challenges and future directions for psychosocial experimental therapeutics.

Parenting and Sibling Relationships in Family with Disruptive Behavior Disorders. Are Non-Clinical Siblings More Vulnerable for Emotional and Behavioral Problems?

Disruptive Behavior Disorders (DBD) are the most common mental health disorders in the school-aged child population. Although harsh parenting is a key risk factor in the shaping of DBD, studies neglect the presence of siblings and differential parenting. This study aims to compare: (1) parenting style and sibling relationship in sibling dyads of clinical families, composed of a DBD child and a non-clinical sibling, with control families composed of two non-clinical siblings; (2) parenting style, sibling relationship, and emotional and behavioral problems in DBD child, non-clinical sibling, and non-clinical child of control group. Sixty-one families (composed of mother and sibling dyads), divided into clinical (n = 27) and control (n = 34) groups, completed the APQ, SRI, and CBCL questionnaires. Results indicated differential parenting in clinical families, compared to control group families, with higher negative parenting toward the DBD child than the sibling; no difference emerged in sibling relationship within sibling dyads (clinical vs. control). Finally, externalizing and internalizing problems were higher in DBD children and their siblings, compared to control, indicating DBD sibling psychopathology vulnerability. Findings suggest inclusion of siblings in the clinical assessment and rehabilitative intervention of DBD children, given that the promotion of positive parenting could improve mental health in the offspring.

Review of Neuropsychological and Electrophysiological Correlates of Callous-unemotional Traits in Children: Implications for EEG Neurofeedback Intervention

Conduct disorder is a significant psychiatric disorder of childhood and adolescence. The Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-5), added the limited prosocial specifier to identify those individuals who exhibit a more severe pattern of behavior characterized by a callous and unemotional (CU) interpersonal style across multiple settings and relationships. This review has attempted to summarize the relevant research focusing on the significance of CU interpersonal style in the development of psychopathy. The primary focus was on the electrophysiological and neuropsychological correlates of CU traits and their implication on the treatment protocol using neurofeedback training for children with such traits. The source of the literature search was PubMed, which majorly uses the MEDLINE database. The keywords used included CU traits, conduct disorder, child psychopathy, empathy, electrophysiology, criminal behavior, neuropsychology, neurofeedback training, and so on. Studies from the last 15 years were considered for the review. This review revealed that children with conduct disorder and high-CU traits with a combination of reactive and proactive aggression are more likely to develop psychopathy. Evidence suggests that these children have distinct forms of electrophysiological and neuropsychological correlates. However, research in this area is still not conclusive as they yield variation in findings. Studies on the efficacy of neurofeedback training on reducing symptoms such as impulsivity, hostility, and psychopathy indicate that neurofeedback training can be a promising treatment alternative for children with severe conduct disorder.

Substance Use Outcomes from Two Formats of a Cognitive-Behavioral Intervention for Aggressive Children: Moderating Roles of Inhibitory Control and Intervention Engagement

Although cognitive-behavioral interventions have reduced the risk of substance use, little is known about moderating factors in children with disruptive behaviors. This study examined whether aggressive preadolescents’ inhibitory control and intervention engagement moderates the effect of group versus individual delivery on their substance use. Following screening for aggression in 4th grade, 360 children were randomly assigned to receive the Coping Power intervention in either group or individual formats. The sample was primarily African American (78%) and male (65%). Assessments were made of children’s self-reported substance use from preintervention through a six-year follow-up after intervention, parent-reported inhibitory control at preintervention, and observed behavioral engagement in the group intervention. Multilevel growth modeling found lower increases in substance use slopes for children with low inhibitory control receiving individual intervention, and for children with higher inhibitory control receiving group intervention. Children with low inhibitory control but who displayed more positive behavioral engagement in the group sessions had slower increases in their substance use than did similar children without positive engagement. Aggressive children’s level of inhibitory control can lead to tailoring of group versus individual delivery of intervention. Children’s positive behavioral engagement in group sessions is a protective factor for children with low inhibitory control.

Orientação a Práticas Parentais: Descrição de um Programa de Intervenção Individual Breve

Resumo A orientação a práticas parentais visa modificar o contexto no qual as crianças estão inseridas como forma de potencializar mudanças em seu comportamento. Esse artigo descreve uma intervenção breve de sete encontros em modalidade individual. O programa teve como finalidades principais auxiliar os cuidadores a identificar e estimular comportamentos adequados em seus filhos; ensinar novos comportamentos; incentivar a autonomia das crianças; encontrar abordagens não-agressivas para lidar com maus comportamentos; e auxiliar na organização da rotina. Como metodologia, realizou-se a descrição de três casos, exemplificando as estratégias adotadas em cada um. A análise dos casos permitiu o delineamento de características comuns entre as práticas parentais dos pais ou cuidadores. Os casos relatados neste estudo evidenciam que as famílias utilizam punição corporal, apresentam dificuldade de empatizar com a criança, possuem um estilo parental autoritário e expectativas incompatíveis com a idade das crianças. Além disso, a infância dos pais ou cuidadores apresentou forte influência no desenvolvimento de suas práticas parentais. A sobrecarga na figura materna também ficou evidente nos casos de famílias intactas. Por fim, a intervenção pode estabelecer um contato inicial da família com um serviço de psicologia, incentivando contato posterior com serviços que possam atender às demais dificuldades. A partir dos resultados examinados, conclui-se que a intervenção breve apresentou resultados positivos na mudança das relações familiares. Porém, o estudo precisa estabelecer uma medição quantitativa antes e depois da intervenção, além de uma sessão de seguimento para verificar se as mudanças são de longo prazo.

The Influence of Treatment Engagement on Positive Outcomes in the Context of a School-Based Intervention for Students with Externalizing Behavior Problems

We examined the stability of and cross-influences between externalizing behaviors and intervention engagement among children participating in a randomized clinical trial of an intervention for disruptive behavioral youth. Analyses also accounted for the influence of caregiver depression, family relationship quality, and sociodemographic factors (race, income) on the relationship between behaviors and intervention engagement. Analyses were based on 118 children participating in the Coping Power intervention. Composite variables were created to represent externalizing behaviors and intervention engagement constructs. Associations between these composite variables were examined over 24 treatment sessions. Findings indicated a regressive relationship among externalizing behaviors, i.e., baseline externalizing behaviors were positively associated with immediate follow-up behaviors. There were also dynamic relationships observed among engagement constructs. Notably, engagement with in-session activities during sessions 1-8 was positively associated with out-of-session activity engagement during the same treatment time period. Engagement with out-of-session activities during sessions 1-8 was positively associated with in-session activity engagement during sessions 9-16, indicating a complete mediation between early and middle in-session engagement through the mechanism of early out-of-session engagement. A crosslag relationship was observed: middle in-session engagement was negatively associated with externalizing behaviors at immediate follow-up. Finally, an interaction of race by income on immediate follow-up externalizing behaviors was observed, such that Black children's externalizing behaviors remain static regardless of income level while White children's behaviors decreased with higher income. Our findings support the contention that focusing on intervention engagement may be especially important in prevention interventions.

Group versus individual format of intervention for aggressive children: Moderators and predictors of outcomes through 4 years after intervention

This study originated in collaboration with Thomas Dishion because of concerns that a group format for aggressive children might dampen the effects of cognitive-behavioral intervention. Three hundred sixty aggressive preadolescent children were screened through teacher and parent ratings. Schools were randomized to receive either an individual or a group format of the child component of the same evidence-based program. The results indicate that there is variability in how group-based cognitive-behavioral intervention can affect aggressive children through a long 4-year follow-up after the end of the intervention. Aggressive children who have higher skin conductance reactivity (potentially an indicator of poorer emotion regulation) and who have a variant of the oxytocin receptor gene that may be associated with being hyperinvolved in social bonding have better outcomes in their teacher-rated externalizing behavior outcomes over time if they were seen individually rather than in groups. Analyses also indicated that higher levels of the group leaders' clinical skills predicted reduced externalizing behavior problems. Implications for group versus individual format of cognitive-behavioral interventions for aggressive children, and for intensive training for group therapists, informed by these results, are discussed.

Theoretical Model of Mindful Coping Power: Optimizing a Cognitive Behavioral Program for High-Risk Children and Their Parents by Integrating Mindfulness

This paper describes a theoretical model of Mindful Coping Power, a preventive intervention targeting high-risk children and their parents. Mindful Coping Power integrated mindfulness into Coping Power, an evidence-based cognitive behavioral intervention. Reactive aggression is emotionally driven, impulsive, and often referred to as being "hot-blooded." It has been resistant to change, given the high level of emotional arousal and impulsive angry outbursts. Our premise is that mindfulness impacts the mechanisms of reactive aggression-attentional, cognitive, behavioral, and emotional dysregulation. Also in the model are parents who exhibit emotionally charged interactions with their child. Mindful parenting focuses on parents' own emotional self-regulation and being fully present with their child. Our model sets the stage for incorporating mindfulness into existing interventions, thereby optimizing programs and maximizing effects.

Cognitive Behavioral Intervention for Youth at Risk for Conduct Problems: Future Directions

This article briefly overviews the history of cognitive behavioral intervention (CBI) for children displaying early signs, or actual diagnoses, of conduct disorders. A series of randomized control trials have identified evidence-based CBI programs for children with these behavior problems at various developmental stages from preschool through adolescence. Although it is critically important for the field to disseminate these existing programs as developed, we argue that it is important to also move beyond the existing evidence-based programs. Research should continue to test new comprehensive, multicomponent interventions, fueled by our evolving understanding of active mechanisms that contribute to children's externalizing behavior problems. The future of research in this area can also benefit from a focus on four central issues. First, research can address how single interventions can have meaningful impact on a range of transdiagnostic outcomes because the intervention mechanisms may affect those various outcomes. Second, rooted in implementation science, we are beginning to understand better how evidence-based programs can be disseminated in the real world, examining key issues such as the adequacy of training approaches and the role of therapist and organizational characteristics. Third, a major focus of research can be on how to optimize intervention outcomes, including a focus on microtrials, on tailoring of interventions, on examining rigorously how interventions are delivered, and on the integration of technology and of other approaches such as mindfulness training into CBI. Fourth, research can explore how the therapeutic relationship and the therapists' characteristics can play substantial roles in effective CBI with conduct problem children.

Empathy in Youths with Conduct Disorder and Callous-Unemotional Traits

Previous studies indicated that a lack of empathy could be considered the core feature of callous-unemotional (CU) traits in children and adolescents. The present study is aimed at exploring relationships among CU traits, cognitive and emotional dimensions of empathy, emotion recognition (basic, social, and complex emotions), and history of maltreatment in a sample of youths with conduct disorder diagnosis. The sample consisted of 60 Italian male patients (age range 11-17 years, mean age 13.27 ± 1.90 years) referred to the Department of Child and Adolescent Psychiatry (Pisa, Italy). In the whole sample, the levels of CU traits were significantly negatively associated with both cognitive and emotional dimensions of empathy; in addition, the CD patients with high levels of CU traits show significantly lower levels of empathic concern compared to those with low levels of CU traits. Clinical implications of the findings are discussed.

Six-year outcome for children with ODD or CD treated with the coping power program

Children with severe aggressive behavioral problems are one of the groups most frequently referred to mental health clinics, and they engage in behaviors that put them at risk for substance use problems and a host of other negative outcomes. The present study aimed to assess the long-term outcome (six-year follow up) of the Coping Power Program delivered in a mental health hospital for children with behavioral disorders. We recruited one hundred and twenty children (mean age = 9.9, SD = 0.85), twenty-three patients were lost during the follow-ups. The sample of the current study included sixty-seven youths with Oppositional Defiant Disorder, and thirty with Conduct Disorder. We used Child Behavior Check List, Inventory of Callous Unemotional traits and a youth survey to evaluate substance use. After the baseline evaluation they were allocated to Coping Power or to a generic multi-component treatment. Coping Power produced significant reduction in Callous Unemotional traits, relative to the control condition; Coping Power seems to be effective also in reducing the rate of substance use. However, no differences have been found in externalizing behavior reduction in the two groups. This study contributes to the successful dissemination of best-practice treatments in public mental health services for children.

Universal Coping Power for pre-schoolers: Effects on children's behavioral difficulties and pre-academic skills

The Coping Power Program has been adapted as a universal prevention model (Coping Power Universal) aimed to reduce children's behavioral difficulties in Italian primary and nursery classes. The current study aimed to determine whether the version of the Universal Coping Power for pre-schoolers could reduce behavioral problems in school and home contexts, and could produce transfer effects on children's pre-academic skills. The sample included 102 five-year-old children who attended six pre-school classes located in Rovigo (Italy). Classes were randomly assigned to the intervention or to the control condition. Both parents and teachers indicated a significant reduction in behavioral problems for Coping Power classes, and teachers rated improvement in children's pre-mathematics, and language abilities. The results of this study are promising, suggesting pre-schoolers' social-emotional and pre-academic skills may benefit from the Universal Coping Power program.

Effect of Comorbid Psychopathology and Conduct Problem Severity on Response to a Multi-component Intervention for Childhood Disruptive Behavior

This study examined the effects of comorbid ADHD symptoms, internalizing psychopathology, Callous-Unemotional (CU) Traits, and conduct problem severity on children's response to an evidence-based psychosocial intervention. Clinic-referred children with DBD ages 8-12 years (N = 76) participated in a 15-week multi-component intervention. Parents provided weekly ratings of children's oppositionality-defiance, peer problems, and impairment. Oppositionality-defiance, peer problems, and impairment decreased significantly over the course of the intervention; however, there was considerable variability in weekly ratings. Baseline ADHD symptoms, internalizing psychopathology, CU traits, and conduct problem severity were unrelated to rate of change across treatment. However, ADHD symptoms uniquely predicted more oppositionality-defiance, peer problems, and impairment averaged across the 15 weeks of treatment. Follow-up analyses suggested this was driven by hyperactivity-impulsivity rather than inattention. Children with DBD and comorbid symptoms appear to benefit from a multi-component intervention, but those with ADHD symptoms may require additional support to address social and behavioral challenges.

Variation in Response to Evidence-Based Group Preventive Intervention for Disruptive Behavior Problems: A View from 938 Coping Power Sessions

Prior research suggests that under some conditions, interventions that aggregate high-risk youth may be less effective, or at worse, iatrogenic. However, group formats have considerable practical utility for delivery of preventive interventions, and thus it is crucial to understand child and therapist factors that predict which aggressive children can profit from group intervention and which do not. To address these questions we video-recorded group Coping Power intervention sessions (938 sessions), coded both leader and participant behavior, and analyzed both leader and children's behaviors in the sessions that predicted changes in teacher and parent, reports of problem behavior at 1-year follow up. The sample included 180 high-risk children (69% male) who received intervention in 30 separate Coping Power intervention groups (six children assigned per group). The evidence-based Coping Power prevention program consists of 32 sessions delivered during the 4th and 5th grade years; only the child component was used in this study. The behavioral coding system used in the analyses included two clusters of behaviors for children (positive; negative) and two for the primary group leaders (group management; clinical skills). Growth spline models suggest that high levels of children's negative behaviors predicted increases in teacher and parent rated aggressive and conduct problem behaviors during the follow-up period in the three of the four models. Therapist use of clinical skills (e.g., warmth, nonreactive) predicted less increase in children's teacher-rated conduct problems. These findings suggest the importance of clinical training in the effective delivery of evidence-based practices, particularly when working with high-risk youth in groups.

Trajectories of callous-unemotional traits from childhood to adolescence in referred youth with a disruptive behavior disorder who received intensive multimodal therapy in childhood

PURPOSE

Our aims were to explore the developmental trajectories of callous-unemotional (CU) traits using a growth curve analysis in Italian children with disruptive behavior disorders treated with a multimodal intervention, and to test both predictors and distal outcomes of CU traits trajectories.

PATIENTS AND METHOD

One hundred and sixty-eight children were enrolled, of whom 24 were lost in the follow-up and 144 were followed up from ages 8-9 to 14-15 years with four assessment points. Patients included 128 males (88.9%) with a mean age of 8.7 years, 96 with oppositional defiant disorder (66.7%) and 48 with conduct disorder (CD) (33.3%). The developmental trajectories of CU traits were assessed with the Inventory of Callous-Unemotional Traits (ICU).

RESULTS

Our findings revealed that CU features were likely to fit a quadratic model from childhood to adolescence. The CU traits tended to decrease during childhood, with stabilization in adolescence and a significant variability in the growth curves. Pretreatment CD and higher levels of externalizing behavioral problems were associated with higher level of CU traits at baseline, whereas positive parenting was associated with lower levels. No significant effects were found for all the other predictors (socioeconomic status, negative parenting, combined pharmacotherapy). Regarding outcomes into adolescence, both higher levels of CU traits at the baseline and a lower decrease of CU traits across time points predicted a higher risk of CD diagnosis, and higher rate of referrals to mental health services and of substance use. Furthermore, pretreatment CD and negative parenting predicted a higher risk of substance use into adolescence.

CONCLUSION

Our findings suggest that a close monitoring of CU traits in referred children with disruptive behavior disorders may help to detect the patients at higher risk of poor outcome.

Moral disengagement and callous-unemotional traits: A longitudinal study of Italian adolescents with a disruptive behaviour disorder

BACKGROUND

Callous-unemotional traits have been proposed as risk factors for a poorer prognosis in young people with disruptive behaviour disorders. Identification of factors that may cause or maintain elevated levels of such traits could help in developing targeted therapeutic interventions. Some previous studies have investigated the role of moral cognitive mechanisms, such as moral disengagement, but these previous studies focused primarily on normal or 'at-risk' samples.

AIM

We aimed to evaluate associations and possible interactions between moral disengagement as a cognitive dimension and callous-unemotional traits as an affective dimension in adolescents with disruptive behaviour disorders.

METHOD

We recruited 55 adolescents with a disruptive behaviour disorder from a community care hospital in Pisa. They were evaluated at baseline and after one year with measures that included a moral disengagement scale, the Antisocial Process Screening Device, to assess callous traits, and the Youth Self-Report, to explore externalising behaviour problems.

RESULTS

Structural equation modelling showed that higher initial moral disengagement scores were associated with later higher levels of callous-unemotional traits in adolescents and vice versa, even after, respectively, controlling for previous levels of callous traits and moral disengagement.

CONCLUSION

As impairments in either cognitive or affective traits may predispose to problematic development of the other, our findings would suggest that screening at the earliest opportunity possible for both moral disengagement and callous-unemotional traits among children with disruptive behaviour disorders could help to map natural outcome pathways and thus tailor more accurate interventions for prevention of antisocial or criminal behaviour. Copyright © 2016 John Wiley & Sons, Ltd.

Coping power for preschool-aged children: a pilot randomized control trial study

AIM

Preschoolers with behavioural difficulties, both at clinical and sub-clinical levels, are at higher risk for several negative outcomes. The current paper reports the results from a randomized clinical trial evaluating an adaptation of the Coping Power for preschool-aged children. In the present study, Coping Power is adapted as a universal prevention intervention, in which teachers deliver a curriculum that is designed to improve children's social competence and reduce problem behaviours.

METHODS

Ten nursery school classes (164 children, mean age 54.40 months) from two Italian schools were randomly assigned to Coping Power or to the control group, which received the standard academic curriculum provided in Italian nursery schools. Teachers in the five intervention classes implemented weekly lessons and extension activities over a 6-month period. Teacher and parent reports of child behaviour assessments were collected at the beginning and end of the school year. At each assessment period, teachers completed the Strengths and Difficulties Questionnaire.

RESULTS

The findings suggest that after exposure to Coping Power, intervention children showed lower levels of behavioural difficulties, rated both by parents and teachers.

CONCLUSIONS

The results of this study are promising and can be interpreted as providing initial support for the efficacy of the preschool version of Coping Power.

Conduct disorders and psychopathy in children and adolescents: aetiology, clinical presentation and treatment strategies of callous-unemotional traits

Conduct Disorder (CD) is a psychiatric diagnosis characterized by a repetitive and persistent pattern of behaviour in which the basic rights of others and major age-appropriate social norms or rules are violated. Callous Unemotional (CU) traits are a meaningful specifier in subtyping CD for more severe antisocial and aggressive behaviours in adult psychopathology; they represent the affective dimension of adult psychopathy, but they can be also detected in childhood and adolescence. The CU traits include lack of empathy, sense of guilt and shallow emotion, and their characterization in youth can improve our diagnostic, prognostic and therapeutic abilities. A strong genetic liability, in interaction with parenting and relevant environmental factors, can lead to elevated levels of CU traits in children. We pointed out that CU traits can be detected in early childhood, may remain stable along the adolescence, but a decrease following intensive and specialized treatment is possible. We here provide a narrative review of the available evidences on CU traits in three main domains: aetiology (encompassing genetic liability and environmental risk factors), presentation (early signs and longitudinal trajectories) and treatments.

Effects of Parent Training on Callous-Unemotional Traits, Effortful Control, and Conduct Problems: Mediation by Parenting

Callous-unemotional (CU) traits and effortful control (EC) are personality and temperament traits implicated in early-onset antisocial trajectories. This secondary analysis of Hitkashrut's randomized controlled trial first tested parent training's effects on EC and CU traits while controlling for more general treatment effects on conduct problems (CP), and subsequently tested mediation by parenting. Prekindergarten teachers in three Israeli cities identified 209 3-5 year-old (163 boys; 46 girls) preschoolers with subclinical-clinical range conduct problems. All participants were Jewish ranging from ultra-orthodox to secular. They were assigned to 14-session co-parent training groups (n = 140 couples), or to minimal intervention control groups with referral to local services as necessary (n = 69 couples). We employed averaged indices of pre- and post-intervention questionnaires completed by both parents. The testing of all hypothesized models controlled for treatment effects on CP in order to strengthen the robustness of the analyses. We found significant concurrent treatment effects on CP and on either CU traits or EC. All effects were mediated by ineffective parenting (IP): a latent variable that was indicated by negative/inconsistent practices and perceived parenting inefficacy. This is the first demonstration of parenting mediated treatment effects on both EC and CU traits in a randomized controlled study conducted in everyday practice contexts. This finding supports a disruption model of change: the reduction of IP facilitates a caregiving environment that affects children's behavior and developing personality. The changing of personality and temperament characteristics implicated in early-onset pathways suggests an innovative prevention strategy for disruptive behavior disorders.

Which dimension of parenting predicts the change of callous unemotional traits in children with disruptive behavior disorder?

OBJECTIVE

Several studies suggested that in addition to child-driven factors (i.e., temperamental style), parenting behavior can, at least in part, influence the maintenance of Callous Unemotional (CU) traits in children; however, more information is needed to distinguish which styles (negative parenting or lack of positive parenting) predict increased levels of CU traits. The aim of the present treatment study was to examine which components of parenting are longitudinally associated with levels of CU traits in children with a disruptive behavior disorder diagnosis.

METHOD

The current study examined cross-lagged reciprocal effects models between positive and negative parenting practices, and the levels of child CU traits over three time points, including both positive and negative dimensions of parenting in the same model. Participants were 126 Italian children with diagnosis of disruptive behavior disorder (oppositional defiant disorder or conduct disorder), 113 boys and 13 girls, 110 Caucasian, 48 with conduct disorder, and 78 with oppositional defiant disorder, treated with a multi-component intervention, based on cognitive behavioral principles and practices. Participants were all 9-10 years of age at the beginning of the study, and were followed-up until the age of 11-12 years (24 months in total, the first 12 under treatment) using parent report (Alabama Parenting Questionnaire and Child Behavior Check List) and child report (Inventory of Callous-Unemotional Traits) measures.

RESULTS

No significant cross-lagged path was found between negative parenting and CU traits; these two variables were also unrelated when positive parenting was considered in the same model. In contrast, reciprocal effects between positive parenting and CU were found: higher levels of positive parenting predicted lower levels of CU traits.

CONCLUSIONS

The current findings suggest that the positive dimension of parenting may need to be targeted in the treatment of DBD children with higher CU traits.