CCPR: Welcome, Dr. Donohue. Let’s start by defining callous unemotional (CU) traits.

Dr. Donohue: I think of them as CU behaviors, especially in young children, because “traits” implies they are not malleable. CU behaviors are characterized by an observable lack of morality such as a lack of empathy, guilt, or prosocial behavior. These children often display shallow emotions; for instance, they may lack connection to parents, feel little sadness when someone is hurting, and show less expression of emotions toward other people. They also often show a lack of motivation; for example, they might not put sufficient effort into schoolwork and extracurriculars.

CCPR: How common are CU behaviors in children?

Dr. Donohue: CU behaviors are present on a spectrum. I’m not aware of many studies that have attempted to assess prevalence, but one community study of 1,136 children (3rd–7th grade) found that 10%–32% of those with conduct disorder and 2%–7% of those without conduct disorder met the CU specifier threshold in the DSM-5.

CCPR: What happens if CU is left unaddressed and untreated?

Dr. Donohue: Active disregard and low empathy in children are strong predictors of conduct problems and antisocial behaviors into adolescence (Rhee SH et al, J Child Psychol Psychiatry 2013;54(2):157–166). Without intervention, untreated CU behaviors can lead to antisocial behavior, criminality, and substance use disorders (Docherty M et al, J Abnorm Psychol 2019;128(7):700–709).

CCPR: What is active disregard?

Dr. Donohue: Active disregard goes beyond not caring and involves taking pleasure in someone else’s pain or sadness. The child might see a boy fall on the playground and laugh or make the situation worse by taunting him or injuring him.

CCPR: What does low empathy look like in children with CU behaviors?

Dr. Donohue: A child with low empathy does not care much or at all when someone else is hurt or sad and typically does not intervene with prosocial behaviors to help the distressed person. A child with high CU might not feel distress or sadness upon seeing that same boy fall on the playground. She might not care enough to comfort him, retrieve a bandage, or get a teacher’s help.

CCPR: Is empathy in young children something that is innate?

Dr. Donohue: Yes, children are biologically wired to experience empathy. You can see this shortly after birth when babies cry in response to other babies crying but not to other equally loud or abrupt noises, and by 3–6 months they display ­other-oriented empathic concern when another person is distressed by looking at or trying to contact and touch the distressed person (Roth-Hanania R et al, Infant Behav Dev 2011;34(3):447–458). Children with CU, however, have deficits primarily in affective empathy, the ability to feel what another person is feeling. Our aim is to help parents or clinicians strengthen a child’s empathy as they develop.

CCPR: So CU behaviors aren’t immutable characteristics?

Dr. Donohue: CU is treatable, especially when children are young and their morality is developing and malleable. CU behaviors have a sizable genetic contribution, but there is no evidence that they become fixed during childhood (Lynam DR et al, J Abnorm Psychol 2007;116(1):155–165; Fontaine NMG et al, J Abnorm Psychol 2011;120(3):730–742). We target emotional and cognitive characteristics of children with high CU through interventions, particularly during early childhood when morality is developing. For instance, we work on identifying fear and sadness in others and being emotionally responsive to others’ emotions.

CCPR: CU behaviors are determined by both genetics and environment then, correct?

Dr. Donohue: Yes. Twin and adoption studies show that CU behaviors often stem from a genetic predisposition combined with certain parenting practices—parenting that is either harsh or low in warmth. Children with high CU traits may have disorganized amygdala networks and/or reduced volumes in the amygdala and medial orbitofrontal cortex. This research needs to be replicated, but it supports early intervention during the increased neuroplasticity before adolescent pruning.

CCPR: Tell us more about warm vs harsh parenting.

Dr. Donohue: Warm parenting includes warm vocal tone, affection, warm praise, and empathy toward the child. Harsh parenting includes negative affect toward the child, criticism, coercion, harsh punishment, frequent negative commands, name calling, overt expressions of anger, and physical threats and aggression including spanking (Waller R et al, J Child Psychol Psychiatry 2012;53(9):946–953; Waller R and Hyde L, Child Dev Perspect 2017;11(2):120–126). One study found that children with a high genetic loading for CU who were raised by an adoptive parent high in warmth displayed lower levels of CU (Hyde LW et al, Am J Psychiatry 2016;173(9):903–910). So interventions that increase parental warmth and decrease harshness can impact the trajectory of CU behaviors.

CCPR: What specific behaviors should we be concerned about in young children?

Dr. Donohue: They may have what we call shallow emotions. Kids with shallow emotions show little reaction or don’t care or feel sad when someone else gets hurt. They may also lack connection to their parents and not gain much pleasure from bonding with others.

CCPR: What do these CU behaviors start to look like as the children enter school age?

Dr. Donohue: Typical children develop prosocial and empathic behaviors such as increased sharing with and caring for their peers and family members. Children with CU have deficits primarily in affective empathy. When they are young, you don’t see prosocial behaviors like sharing, taking turns, or coming to the aid of upset or injured peers. When they enter school, the deficits become more apparent. If they see an injured peer, they may laugh or try to hurt the person. If their friend is sad, say, about dropping their ice cream cone, a child high in CU might not care about their distress. As children age, they may show less than usual concern about social norms or little interest in schoolwork and extracurriculars. Older kids and teens start showing symptoms of conduct disorder, such as stealing, bullying, and hurting others, all with little emotion or fear of consequences.

CCPR: What about autism where kids may look or seem like they don’t care? How would we tell the difference?

Dr. Donohue: Children with autism also display empathic deficits, but those are very different etiologically (Klapwijk ET et al, J Child Psychol Psychiatry 2016;57(6):737–747; O’Nions E et al, Dev Sci 2014;17(5):786–796). Kids with autism primarily have deficits in cognitive empathy, the ability to understand what another person is experiencing. So if a child with autism doesn’t like ice cream, he might not understand why his friend is sad that they dropped their cone on the ground.

CCPR: We see kids all the time with depression who seem detached and don’t care. How do we make the distinction in this case?

Dr. Donohue: Children with depression might be less connected to others and struggle with motivation; however, they do not display the true lack of caring about others that we see in kids with CU behaviors. In fact, children with depression often display excessive moral emotions, such as too much guilt, rather than a lack of those emotions.

CCPR: Do cultural differences impact your understanding of CU traits, including chronic cultural trauma or other social determinants?

Dr. Donohue: There is a lack of research exploring cultural differences in CU. One meta-analysis comparing Black versus White individuals found no differences in levels of CU traits (Skeem JL et al, Law and Human Behavior 2004;28(5):505–527). But trauma or adversity, including adversity in early life, might cause secondary CU in children as a way to cope and detach from their experiences. That has potential implications for minority populations who, in the US, are more likely to live in poverty and undergo adverse childhood experiences.

CCPR: So trauma and neglect can result in CU behaviors and a lack of emotion?

Dr. Donohue: Yes. Researchers describe primary and secondary subgroups of children with CU (Craig SG et al, Clin Child Fam Psychol Rev 2021;24(1):65–91). Children with primary CU are fearless, with low levels of anxiety. These behaviors are thought to be caused by insufficient arousal or distress when they are punished or when others are distressed. Children with secondary CU have high levels of co-occurring anxiety and are more likely to have histories of physical and sexual abuse and other trauma. Similar to what happens in PTSD, we think that children with secondary CU may develop tendencies to numb their emotions regarding what’s going on around them as a coping response to trauma.

CCPR: How can we assess children for CU traits?

Dr. Donohue: Familiarize yourself with some clinical scales like the Inventory of Callous-Unemotional Traits (ICU; www.tinyurl.com/ye73f6sv). This is a 24-item parent report for young children, with a self-report version for 11- to 17-year-old children. Another scale I like is the Map DB Low Concern Scale (Wakschlag LS et al, Am J Psychiatry 2018;175(2):114–130). It’s a nine-item parent report for preschool-age children and spans the spectrum from displaying low empathy, prosociality, and guilt to taking active pleasure when another person is distressed. You can either use these scales informally or in a more structured way.

CCPR: What treatments do you recommend for CU?

Dr. Donohue: CU is tough to treat. However, several recent interventions have demonstrated success in treating CU behaviors. Look for therapists who use parent child interaction therapy (PCIT; www.tinyurl.com/3a7vbcp3). If you have the time, you can learn it yourself. There are several adaptations of PCIT, such as for children with CU. These therapies increase parental warmth and help children get more pleasure from initiating and maintaining interpersonal connections within the parent-child dyad. They also help children learn to identify and respond to emotions in others and help parents use positive reinforcement instead of punishment since children with high CU traits tend to be punishment insensitive. Other adaptations of PCIT target empathy, prosocial behaviors, and ability to understand others’ distress (Editor’s note: See “Parent-Child Interaction Therapies for Preschoolers” table).

CCPR: Are there things we can do while we search for therapists who know PCIT and other more specific treatments for CU behaviors?

Dr. Donohue: I recommend that clinicians look for trauma, recognize these kids are punishment insensitive so positive rewards work best, work on increasing parental warmth, and avoid giving up hope. We can increase empathy in kids, helping them recognize and respond to emotions in themselves and others. I also recommend social skills groups for children struggling with CU traits, which may be easier to find and will give them the opportunity to interact with other children. And evidence-based positive parent-child interventions, even if they are not PCIT, are worth pursuing.

CCPR: Does the subtype of CU affect treatment?

Dr. Donohue: Unfortunately, to my knowledge, there’s no clear research on this. It is possible, for example, that targeting empathic processes such as learning to identify and respond to emotions in other people might be most effective for kids with primary CU. If a child is displaying secondary CU behaviors because of trauma, perhaps evidence-based treatments for trauma could have downstream effects on CU behaviors.

CCPR: How effective are the treatments for CU behaviors in children?

Dr. Donohue: In our study, PCIT for emotional development maintained decreased CU at a three-month follow-up, though we need data on more distal follow-up (Donohue MR et al, J Am Acad Child Adolesc Psychiatry 2021;60(11):1394–1403). Mark Dadds has an individual empathy intervention that increases the accuracy of perceptions and interpretations of others’ emotions and improves affective empathy in children with CU (Dadds MR et al, Psychiatry Res 2012;199(3):201–207). The field is focused on why CU develops, particularly in very early childhood, which will help us develop better interventions that target specific emotional deficits in children with CU.

CCPR: Can relying on external rewards make kids dependent on those rewards and prevent the development of internal standards?

Dr. Donohue: I don’t think so. Rewards such as positive reinforcement can shape behaviors in young children, and experiencing the natural positive consequences of those new behaviors can feed intrinsic motivation. Still, positive reinforcement from a parent is more than simply an effort to shape behaviors. It’s part of bonding with and showing positive regard for the child.

CCPR: Is there a role for medication in treating CU behaviors?

Dr. Donohue: There are no specific medications to treat CU behaviors. However, it is important to treat comorbid conditions that can accompany CU behaviors such as ADHD, depression, and any other severe conditions (eg, disruptive mood dysregulation disorder, psychosis, bipolar disorder, or irritability in autism).

CCPR: Any closing thoughts?

Dr. Donohue: We know that empathy, guilt, and prosociality can be socialized by parents and other caregivers, and there are treatments being developed and tested that are showing promising effects on CU behaviors in young children. So, I think the science on CU behaviors and the development of morality more generally paints a very hopeful picture for children struggling with CU behaviors.

CCPR: Thank you for your time, Dr. Donohue.

Table: Parent-Child Interaction Therapies for Preschoolers
For a full PDF of the table, click here