Emotional reactivity in referred youth with disruptive behavior disorders: The role of the callous-unemotional traits
Introduction
Disruptive Behavior Disorders (DBDs), including Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD), are among the most common reasons for youth referrals to mental health clinics (Steiner and Remsing, 2007) and can be associated with psychosocial impairment, poor prognosis and antisocial outcomes (Fergusson et al., 2005). A major goal in clinical research is to discover possible predictors of negative social outcome of DBDs, according to specific clinical, personality and temperamental variables on one side, and social and environmental variables on the other. These factors may allow further subtyping of the broad category of DBDs into more specific and homogeneous groups, improving intervention strategies (Mason et al., 2004, Vaughn et al., 2011). According to the recent DSM-5, DBDs are classified into a new cluster, named Disruptive, Impulse-control and Conduct disorders, including disorders characterized by difficulties in emotional and behavioral self-control (American Psychiatric Association, 2013).
Among the clinical specifiers for a high-risk antisocial pattern, the DSM-5 has included limited pro-social emotions (Pardini et al., 2010, Burt et al., 2011). This proposed specifier is diagnosed if the patient meets full criteria for CD, and shows two or more of the following characteristics persistently over at least 12 months in more than one relationship setting: lack of remorse or guilt, callous-lack of empathy, unconcerned about performance, shallow or deficient affect. Individuals with callous-lack of empathy are cold and uncaring, and unconcerned about the feelings of others, even when their behavior results in harm to others. They do not express feelings and do not show emotions to others, or their emotions are insincere and used to manipulate others. These features were previously included in the concept of Callous Unemotional (CU) traits (Frick et al., 2003, Frick and White, 2008), and are also considered core elements in the clinical descriptions of adult psychopathy (Blair et al., 2006b). An additional feature of the CU traits is their stability from childhood to adolescence (Burke et al., 2007) and adulthood (Lynam et al., 2007). Previous research has shown that CU traits in childhood and adolescence have been related concurrently and prospectively with a higher rate of conduct problems (Rowe et al., 2010, López-Romero et al., 2011, López-Romero et al., 2012), aggressive behaviors (Marsee and Frick, 2007), and lower levels of pro-social behavior and social skills (Viding et al., 2009).
A significant body of research has been devoted to understanding temperamental and biological underpinnings of CU traits and psychopathy (Marsh et al., 2008, Viding et al., 2008, Viding et al., 2013, Jones et al., 2009), and also emotional reactivity to external stimuli has been explored in youth with high CU traits, as recently reviewed in Herpers et al. (2014). Children, adolescents and adults with psychopathic-like traits show some deficits in processing of negative emotional stimuli, or are less accurate in identifying sad facial expression (Kimonis et al., 2006, Woodworth and Waschbusch, 2008). A deficit in subjective arousal to fear and distress may lead youths to experience a lower impact of the negative consequences due to their own behaviors (Blair et al., 1997, Blair et al., 2001, Blair et al., 2006a, Blair et al., 2006b). The same emotional feature may also be associated with a reduced sensitivity to behavioral interventions (i.e., punishment) (Blair et al., 1997, Blair et al., 2001, Blair et al., 2006a, Blair et al., 2006b). A lower fear of social punishment may explain why youth with high CU traits are less responsive to treatment than peers with conduct problems, but low CU traits (Hawes and Dadds, 2005, Masi et al., 2013). A better understanding of the nature of CU traits can thus target more efficient treatment strategies specifically geared to the specific needs of the patients.
The International Affective Picture System (IAPS) is one of the most reliable and valid instruments for the experimental investigation of emotions based on a set of visual stimuli for the exploration of the relationships between the affective valence of the emotional stimuli (from pleasant to unpleasant), and the individuals׳ reaction in terms of arousal to emotional stimuli (from excited to calm) (Lang et al., 1999). Recently, IAPS has been applied to youths, based on norms by Lang et al. (1999). Early studies support the validity of IAPS for use in young samples from the community (McManis et al., 2001), as well its utility the exploration of psychopathic-like traits and conduct problems (Sharp et al., 2006, Sharp et al., 2008). Following McManis et al. (2001) work with pre-adolescent children, words like happy, pleased, good, and unhappy, scared, angry, bad or sad were used in the instructions to describe the endpoints of the pleasure (valence) scales. Words like calm, relaxed, bored, or sleepy and excited, nervous or wide-awake described the endpoints for the arousal scale. Sharp et al. (2006) selected 27 IAPS pictures to explore a wide range of affective content in a large unselected community cohort of 659 children aged 7–11, while concurrent symptoms of DBDs and psychopathy were collected from multiple sources. According to this study, children above the cut-off on measures of antisocial behavior presented lower arousal to unpleasant picture, but higher arousal to pleasant picture.
A recent article by Herpers et al. (2014) reviewed the current literature on neurocognitive aspects of CU traits in youths. A lower emotional responsivity to distressing stimuli was found in the majority of studies, as well as a reduced response of the amygdala and a weaker connectivity between amygdale and the ventro-medial prefrontal cortex, suggesting impaired emotional reactivity over and beyond conduct problems. These findings are in line with other studies, suggesting that specific emotion processing deficits, namely in the response to sad or fear stimuli, are related to changes in brain structure and function (Fairchild et al., 2013, Frick et al., 2014). These issues support the interest in using IAPS pictures in CD, as they comprise a various set of different emotions.
The current study on referred Italian children and adolescents with DBDs, is aimed at further exploring emotional reactivity associated with the presence of CU traits. Our hypothesis is that youth with DBDs that may show a different emotional subjective experience, evaluated on a self-report clinical scale, compared to healthy subjects. Based on previous neurobiological and psycho-physiological studies (Patrick et al., 1993, Fowles, 2000, Van Goozen et al., 2007, De Wied et al., 2009), the presence of CU traits could be associated with reduced arousal and increased valence subjectively perceived against negative visual stimuli. The questions addressed in this study are therefore the following: 1) is there a specific pattern of emotional response, in terms of valence, arousal, or both in referred youth with DBDs, compared to healthy controls? 2) is there any relationship between arousal/valence facing emotional engaging stimuli and high level of CU traits?
Section snippets
Participants
The clinical sample consisted of 62 children and adolescents with DBDs (ODD and/or CD), (51 males, age-range 8 to 16 years, mean age 11.3±2.1 years), consecutively referred to two third-level Italian departments of Child and Adolescent Psychiatry, settled in the Scientific Institute “Stella Maris” in Pisa and the Scientific Institute “Bambino Gesù” in Rome from January 2012 to February 2013. Our clinics are research hospitals with a national catchment for children and adolescents presenting a
Comparison between groups according to CBCL and ICU
As expected, significant group differences resulted in all total scores and subscales (both externalizing and internalizing) at CBCL, as well as ICU callous and indifferent subscales. ICU unemotional subscale did not differ between clinical and control groups (Table 1).
Comparisons between groups according to IAPS
In the valence dimension, a group difference was found for neutral (F=11.46, d.f.=113, p=0.01) and negative images (F=16.6, d.f.=113, p<0.001), but not for positive stimuli (F=0.33, d.f.=113, p=0.565). No group difference was
Discussion
In present paper, we aimed at further exploring emotional reactivity in a sample of DBDs youths, and its possible relationship with CU traits. In this study we used well validated self-report measures, such as IAPS and ICU. Scheepers et al. (2011) pointed out the importance of self-reports for the assessment of CU traits in youth, as it is related to interpersonal thoughts and feelings, which may be hardly recognized and reported by parents.
Consistently with the existing literature (Frick et
Conflict of interest
Dr. Masi was in the advisory boards for Eli Lilly and Shire, has received research grants from Eli Lilly and Shire, and has been speaker for Eli Lilly, Shire, Lundbeck, Otsuka and Novartis. Dr. Vicari was in the advisory boards for Shire, has received research grants from Eli Lilly and Shire, and has been speaker for Eli Lilly, Shire. Dr. Mazzone has received travel grant from Shire and has been speaker for Eli Lilly. All the other authors do not have conflicts of interest to declare.
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