Callous unemotional behaviors can be challenging to understand. One community study of 1136 children (from 3rd-7th grade) found that 10%–32% of those with conduct disorder and 2%–7% of those without conduct disorder met the callous emotional specifier threshold in the DSM-5. In this episode, we will discuss what callous unemotional behaviors are, how they look like, how to assess these behaviors, types of interventions, and more. 

Dr. Meghan Rose Donohue joins us today to help us unpack this topic. She is an instructor in psychiatry and works in the division of child and adolescent psychiatry at Washington University School of Medicine.

Published On: 12/18/2023

Duration: 24 minutes, 33 seconds

Transcript:

Dr. Feder:  Welcome to The Carlat Psychiatry Podcast.

This is another episode from the child psychiatry team.

I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice  - our second edition is coming out in early 2023!

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice. 

Callous unemotional traits, better defined as callous unemotional behaviors are characterized by an observable lack of morality such as a lack of empathy, lack of guilt, or lack of prosocial behaviors. Children with callous unemotional behaviors often display shallow emotions, for example they may lack connection to parents, feel little sadness when someone is hurt, and show less expression of emotions toward other people. They also show a lack of motivation; for instance, they might not put sufficient effort into schoolwork and extracurriculars.

While these behaviors can seem frightening to many parents, it is important to remind them that callous unemotional behaviors are treatable, especially when children are young and morality is developing and malleable. Callous unemotional behaviors have a sizable genetic contribution, but there is no evidence that they become fixed during childhood. We can target emotional and cognitive characteristics of children high in callous unemotional behaviors in interventions, particularly in early childhood when morality is developing.

Dr. Feder, what happens if callous unemotional behaviors are left unaddressed or untreated?

Dr. Feder:  Children who have an active disregard for others or low levels of empathy these are strong predictors of conduct problems and antisocial behaviors into adolescence. Without intervention, untreated callous unemotional behaviors can lead to antisocial behavior, criminality, and substance use disorders. 

Mara: Is empathy innate in young children?

Dr. Feder: Yes, children are biologically pre-wired to experience empathy. You can see this shortly after birth when babies cry in response to other babies crying but not to other other equally loud or abrupt noises. By 3–6 months they display other-oriented empathic concern when another person is distressed. They show this by looking at or trying to contact and touch the distressed person. Children with callous unemotional behaviors, 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.

Mara: What do low empathy and active disregard look like in children with callous unemotional behaviors?

Dr. Feder: A child with low empathy does not care much or does not care at all when someone else is hurt or sad, and typically does not intervene with prosocial behaviors like going to comfort the hurt person. So a child with high callous unemotional behaviors sees that same boy fall on the playground and might not feel distress or sadness. That child might not care enough to comfort the boy, retrieve a Band-Aid, or get a teacher’s help. Active disregard goes beyond just not caring. The child takes pleasure in someone else’s pain or sadness. For example, a child might see a boy fall on the playground and laugh or make the situation worse by taunting him or injuring him again.

Mara: Is there an environmental component to the development of callous unemotional behaviors in children?

Dr. Feder:  Yes. Twin and adoption studies show that callous unemotional behaviors often stem from a genetic predisposition combined with certain parenting practices—either parenting that  lacks warmth or that is frankly harsh. Children with high callous unemotional behaviors 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. 

Mara: Can you elaborate on what you mean by warm versus harsh parenting?

Dr. Feder: Warm parenting includes warm vocal tones, 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. One study found that children with a high genetic loading for callous unemotional behaviors who were raised by an adoptive parent high in warmth displayed lower levels of CU. So interventions that increase parental warmth and decrease harshness can impact the trajectory of callous unemotional behaviors.

Mara:  Typical children develop prosocial and empathic behaviors such as increased sharing with and caring for their peers and family members. Children with callous unemotional behaviors have deficits primarily in affective empathy,  the ability to feel what another person is feeling. 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 callous unemotional behaviors 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 to show symptoms of conduct disorder, such as stealing, bullying, hurting others, all with little emotion or fear of consequences. 

Dr. Donoghue, how do we distinguish callous unemotional behaviors in children with autism?

Dr. Donoghue: The autism question is interesting because children with CU traits and children with autism both display empathic deficits, but they’re thought to be very different and there is actually some research showing that those are very different etiologically. So, it’s really thought that children with CU traits have deficits primarily in affective empathy, so the ability to feel what another person is feeling; whereas children with autism primarily have deficits in cognitive empathy, so the ability to understand and apprehend what another person is experiencing. And so, those are very different manifestations of that.

Dr. Feder: How do we distinguish callous unemotional behaviors in children with depression?

Dr. Donoghue: When I was in grad school, I studied more of the basic science development of morality in very young children, so basic science questions about what does empathy and prosocial and guilt development really look like in the very earliest developmental stages like infancy and toddlerhood? Then I also looked at ways in which the overdevelopment of empathic emotions contributes to risk for psychopathology. So, for instance, children with depression that tend to experience maladaptive guilt where they might have guilt that’s excessive. So, kind of more of that overdevelopment.

Dr. Feder: So it sounds like depressed children might be less connected to others and struggle with motivation; however, they do not display the true lack of care about others that we see in kids with callous unemotional behaviors. In fact, children with depression often display excessive moral emotions, such as too much guilt, rather than too little. 

Dr. Donoghue: Exactly.

Dr. Feder: Do cultural differences impact your understanding of callous unemotional behaviors, including chronic cultural trauma or other social determinants?

Dr. Donoghue: Yeah, it’s an interesting question and it wasn’t one that I knew the answer to, so I did a literature search, and I came up empty. I mean, I wasn’t able to find any studies that looked at cultural or racial or ethnic differences and CU behaviors in young children. I did find one metanalysis looking at levels of CU traits. I can’t remember if it was CU traits or psychopathy, but the sample was just comparing black versus white individuals, and they found no differences.

So, I don’t think this is something that’s been well-researched and the small amount of evidence we have seems to suggest that there aren’t racial differences in levels of CU traits, but it’s worth thinking about the impact of trauma and adversity and early childhood adversity potentially causing secondary CU traits in children down the line as kind of a way to cope and detach from their experiences. I think that potentially has implications for under-represented minorities who are more likely to be living in poverty and more likely to experience adverse childhood experiences.

So, I think that one of many, many, many reasons to start targeting poverty and trying to really – yeah, target poverty and reduce adverse childhood experiences in children and especially when we know that these experiences of poverty and adverse childhood experience disproportionately fall on certain individuals in our country, rather than others.

Dr. Feder: How can trauma and neglect result in a lack of emotion and callous unemotional behaviors?

Dr. Donoghue: So, conduct problems are really the most strongly associated with CU traits so within children with serious conduct problems, CU traits tend to designate kids that are particularly severe and aggressive. Children with these high CU traits tend to show a more severe and stable pattern of conduct problems and then later antisocial behavior, so it’s really predictive of both concurrent conduct problems and conduct problem severity and then future conduct problem severity and antisocial behavior, criminality, substance use disorders.

It's really most associated with conduct problems and antisocial behavior but interestingly, when you talk about PTSD specifically, it’s interesting. There are thought to be two groups of children with CU traits, and they’re identified by their level of concurrent anxieties. So, early on researchers hypothesized that anxiety was incompatible with CU traits because children with CU traits were supposed to have this fearless temperament, right? And so, they thought that then anxiety disorders would be really incompatible with CU traits. 

But researchers have since identified that there are these two subgroups of children with CU traits. They’re called primary and secondary. Children with primary CU traits are children who display the fearless temperament and tend to display really low levels of anxiety. And children with secondary CU traits, though, this group has been identified as children that do have high levels of CU traits, but they tend to have really high levels of anxiety as well. And a kind of key distinguisher here is these children tend to have much greater histories of physical and sexual abuse and other trauma.

And so, the etiologies of CU traits in these groups are thought to be different. In children with primary variants, the CU traits are thought to be caused by insufficient arousal to emotional cues that I’ve kind of been talking about. You know, being insufficiently distressed when others are distressed, being insufficiently distressed by punishment and with the secondary variant, it’s thought to kind of be developed as a coping mechanism to trauma or adversity.

So, I think that that is an interesting area of research where anxiety was thought to be kind of antithetical to this construct or condition. But then this group of children with secondary CU traits has been identified that’s thought to be kind of this response to trauma. So, I think that can kind of tie in with PTSD and exactly what you’re saying of kind of the idea is more a response to trauma as a kind of a way to numb. So, not caring about others’ distress and not being empathic and prosocial to others’ distress because there’s trauma and abuse going on and it’s a way to kind of numb emotions to what’s going on around them.

Mara: When you assess children with callous unemotional behaviors, familiarize yourself with some clinical scales like the Inventory of Callous-Unemotional Traits (ICU). 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. It’s a nine-item parent report for preschool-aged 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.

Dr. Donoghue, what treatments do you recommend for callous unemotional behaviors and how effective are they?

Dr. Donoghue: So, in older children with CU behaviors and kind of older studies have found some success in parenting interventions and so, the specific types of parenting that our research suggests are most important to CU behaviors, really, parenting warmth is really important. So, often with kids that have severe conduct problems, but they do not have high levels of CU traits, it’s really harsh parenting that’s thought to be the important target. So, you know, lowering harsh parenting.

But for children with high levels of CU traits, it’s really thought to be the absence of warm parenting that is an issue for these kids. Interventions have been shown to be effective in older children that really modify parenting, and there currently some adaptations of PCIT that have been developed that really target increase in parenting warmth for these children.

And really, why that’s thought to be really important for children with high CU traits is because in talking about their temperamental characteristics, children with CU traits have been found to be really low on what’s called “affiliative rewards”, a kind getting pleasure from initiating and maintaining interpersonal bonds, so basically it’s thought that a child that has kind of more of this natural lack of pleasure in seeking out and maintaining interpersonal bonds in the presence of a parent that also does not kind of cultivate or facilitate that, that it is a particularly kind of risky combination. So, yes, there are some interventions that have targeted parenting that have been found to be effective.

And then, like I kind of alluded to, now in younger children there are interventions that are being developed that are really targeting more of the unique and emotional and cognitive characteristics of children. There were a lot of PCIT adaptations that have kind of adjunctive modules that target emotional development for these kids, so they contain the parenting intervention that targets increasing parenting warmth in the dyad that they also contain a specific module that’s aimed to target increasing empathy and pro-social behaviors and ability to understand others’ distressed views.

There’s one, for example, by Eva Kimonis’ and Mark Dadds’ group. It’s called PCITCU, and that has come out in the past couple of years, their trial on that and it’s basically traditional PCIT and then there’s an adjunct module they call the CARES module, and it really targets certain characteristics of children with high CU traits and so that was found to be effective in actually reducing children’s CU traits. And that’s in pre-school age children.

And then my mentor that I studied with in post-doc, Joan Luby, has another PCIT intervention called “PCIT ED,” so the ED is emotion development. And it’s similar. It is standard PCIT and then there’s a module at the end that was developed to enhance emotional development. This was not developed to treat CU, but I did a post hoc analysis on it to see if actually did decrease CU behaviors because there are a lot of components of the intervention that I thought would be effective. So, it tries to teach in positively reinforced pro-social and empathic behavior. And there are a lot of other aspects of it that I thought would be beneficial to children with CU traits, and that intervention has also been found to decrease CU traits in young children. This was pre-school age children.

But when you’re talking about kind of trajectories, I think the verdict is still out on how far reaching the benefit of these treatments is. So, in our study we found that that intervention decreased CU traits and that was maintained at a 3-month follow up, but we don’t have data on more distal follow up time points in order to know exactly how far-reaching the benefit goes.

Dr. Feder: Can the reliance on external rewards make kids dependent and prevent the development of internal standards?

Dr. Donoghue: I think that positive reinforcement can be a really strong way to shape a behavior in a young child than then they’re going to receive natural consequences of those new behaviors that then will feed into them having intrinsic motivation.

There is some debate over whether it’s a good idea to try to shape behaviors or skills like empathy and pro-social behavior using external motivation when we want this to be something that’s internally motivated.

But I think when you’re talking about parenting, it’s a little more complex because positive reinforcement from a parent is not just an effort to shape behavior. It’s really part of the bonding and positive regard for the child. So, I think it’s a little more complex than probably it’s not just about the reinforcement, but those parenting tactics there to kind of increase positive regard in the dyad and give the child that feedback from their parent like kind of more of the warm parenting feedback that’s important.

Dr. Feder:  As we search for other specific treatments for callous unemotional behaviors and therapists who know Parent Child Interaction Therapy, there are still steps we can still take as clinicians. Evidence based positive parent-child interventions, even if they are not Parent Child Interaction Therapy, are worth the pursuit.

Most important: The behavior of these kids can be disheartening. Don’t allow yourself to be paralyzed by hopelessness. Look for trauma in the history to give you an idea of whether the child might have the more fearless primary or more anxious secondary type of CU behaviors. That will be a clue to how to proceed. When you counsel parents figure out whether the child is  insensitive to punishment . If so positive rewards will work best. And support parents to increase their parental warmth. This is not so straightforward when parents are exhausted and worried, or when they themselves have histories of similar situations. You may need to listen and think with parents to hear their stories and help them work to support their child in a warm manner despite the strong feelings they may have about their child’s CU behaviors. For the kids themselves we can increase their empathy, helping them recognize and respond to emotions in themselves and others. Look for social skills groups specifically for children who struggle with callous unemotional behaviors. These are places where children can interact with other children in a therapeutic setting. 

You might wonder whether there are medications to treat callous unemotional behaviors. Well, there aren’t any. However, it is important to treat comorbid conditions that can accompany callous unemotional behaviors, such as ADHD, depression, and any other severe conditions such as DMDD, psychosis, bipolar disorder, or irritability in autism. As one example, remember that for kids with ADHD and aggression, you can successfully help the aggression about 60% of the time if you titrate a first one stimulant, usually methylphenidate, and if that doesn’t work dextroamphetamine. 

Mara: Dr. Donoghue, do you have any closing thoughts?

Dr. Donoghue: I think maybe something that’s really important that we didn’t really touch on that’s I think really important for us as clinicians and for researchers to keep in mind is one of the reasons I like to say CU behaviors instead of CU traits is because I don’t believe there’s any evidence that these are immutable characteristics or that they’re any more stable than any other personality traits that we come across and I think it’s really important to keep in mind the type of stigma that some of these labels can hold for children and for children in the justice system. I think it’s just really important to keep that in mind when we’re seeing kids clinically and looking at them as having difficulty with something that is treatable, that’s workable, that’s really worth working on.

Like moral development is – hopefully, I don’t need to kind of sell the importance instilling moral development in our youth. I think it’s so related to many really important outcomes; you know, criminality and violent crime and substance use, and really long-standing patterns of antisocial behavior and I think it plays a big role in all aspects of life. So, I think it’s important to look at these kids as very treatable and going through something that we can work with them on and especially when they’re really young and morality’s really, really developing and it’s malleable and that it’s an important thing to work on as early as we can and to keep the outlook that these are just behaviors and they’re not immutable traits.

Dr. Feder: Our upcoming printed interview with Dr. Flaherty will be available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads, and our authors don’t receive industry funding. That helps us to bring you unbiased information you can trust. 

Mara: As always, thanks for listening and have a great day!

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