5: CD CU

Question 1

The problem is that aggressive and violent behaviour is a massive problem.

Scott et al., 2001

Cohen, 2005

Odgers et al., 2007

Answer 1

The problem is that aggressive and violent behaviour is a massive problem. Antisocial behaviour is extremely costly to society in terms of the financial cost (Scott et al., 2001) of putting a child with behavioural problems through a specialised educational system or the criminal justice or that young person through the adult prison system later on. Its also very costly for victims (Cohen, 2005), the bottom line is people that do AB are not doing well. There are poorer physical and mental health outcomes for those involved in AB (Odgers et al., 2007).

Question 2

For a while prevention is a priority, the labour government from a while ago, had their ‘Respect’ agenda,

Answer 2

For a while prevention is a priority, the labour government from a while ago, had their ‘Respect’ agenda, which was about addressing antisocial behaviour in society, the NHS had violence prevention as a research priorities a few years ago and the world health organisation has had violence prevention as one of its strategic priorities in the recent past as well. Therefore, it is something that is seen nationally and internationally and thus its imports to try and tackle. About 6% of males and 2% females at peak of population are involved in antisocial behaviour, to the extent that they meet the criminal justice system at the most severe end. At the less severe end there will be a really big selection of antisocial behaviours, theta are reasonably low level but persistent e.g. excessively noisy neighbours, illegal behaviours.

Question 3

Offenders as a percentage of the population: England & Wales 2004:

Answer 3

Offenders as a percentage of the population: England & Wales 2004: The chance of becoming an offender peaks around adolescence, which is slightly earlier for females but in males it peaks in late adolescence and declines across the lifespan. There are probably two reasons for this 1) people grow up/mature (its generally fairly difficult to be a criminal as you get into your older years) but also because if a person is an offender at this age and they join the criminal justice system, it might take a while before they come out (some of these people might be in the criminal justice system for quite a long time) which removes them from jumping back into this behaviour.

Question 4

People that are antisocial, aren’t all doing it for the same reasons, this perspective is equifinality:

Answer 4

People that are antisocial, aren’t all doing it for the same reasons, this perspective is equifinality: The same behaviour can be driven by different reasons/vulnerabilities (there is not one reason a person becomes antisocial). By understanding the developmental pathway for different subtypes may offer important clues for interventions as there is not a one size fits all model for treating people with antisocial behaviour problems. A person might get involved in crime because they are in really terrible SES situations and can’t feed their family so they start stealing. This person in very different from someone who is working in city and committing fraud. Therefore we are interested in what the reasons are and what the developmental pathways are that put people on a trajectory for an antisocial outcome.

Question 5

The DSM-V thinks about CD in the same way as it has done for long time, it that it is a

Answer 5

The DSM-V thinks about CD in the same way as it has done for long time, it that it is a repetitive and persistent pattern of behaviour the violates the rights of others (assault, vandalism, theft) or major age-appropriate societal norms (truancy, running away, deceitfulness). It is the most common psychiatric disorder in childhood this true in the US because we don’t use it as a label in the UK. IN the UK we use emotional and behavioural problems that are linked to other disorders rather than a specific disorder. Children that fulfil criteria for CD (the amount of antisocial behaviours seen) however, the estimated lifetime prevalence in US is 9.5% (Nock et al., 2006) which is really high considering that the lifetime prevalence rate for ASD is 1%. There is a gender difference, it is more common in boys: 12% v. 7.1% which changes a little in adolescence when girls start to catch up a bit. In earlier childhood its much more prevalent in boys whereas during adolescence girls show a greater prevalence too. There are many co-morbid conditions which include ADHD, anxiety, depression and substance abuse.

Question 6

The Rates of CD by age and gender (1999 ONS national survey, n=10,450),

Answer 6

The Rates of CD by age and gender (1999 ONS national survey, n=10,450), there are always more boys than girls but girls start to catch up around adolescence due to a normative desire to push against the boundaries. Some people do it more than others and take it to an extent where its really problematic. Usually, there is a idea that affiliation with delinquent peers is a problem at this point.

Question 7

There are lots of co-morbidities, CD is not a stand alone condition.

Answer 7

There are lots of co-morbidities, CD is not a stand alone condition. It is rare for ODD/CD to occur outside the context of other psychiatric disorders (Greene et al., 2004). Most commonly ADHD is diagnosis along side CD and many children have a diagnosis of operational defiant disorder ODD, which is like the precursor to conduct disorder. ODD is much more likely to be diagnosed in younger children. 65% of children diagnosed with ADHD also had ODD. 80% of children diagnosed with ODD also had ADHD (problems with inhibition and regulating behaviour. A huge proportion (70%) of children who have severe depression also have behavioural difficulties (ODD). Behavioural difficulties are usually a communication that life is not going well. 45% of children diagnosed with an anxiety disorder also had ODD. A very large proportion of children diagnosed with bipolar disorder (85%) also had ODD. Also, there are quite a lot (55%) of children diagnosed with language disorders also have ODD. Children who probably can’t communicate effectively at the same level of their peers are using other methods to communicate and this methods may be aggression and acting out.

Question 8

The prognosis of Conduct Disorder is mixed. More than half of children with conduct disorder do not become antisocial personalities in adulthood (Loeber, 1991; Zoccolillo et al., 1992).

Lahey et al., 1995
Rutter, 2008
Sheila Hogins

Answer 8

The prognosis of Conduct Disorder is mixed. More than half of children with conduct disorder do not become antisocial personalities in adulthood (Loeber, 1991; Zoccolillo et al., 1992). Most of those that do not go on to become antisocial adults will have only started behaving antisocial during adolescence. There is a group of children who are an early onset limited type who stop being antisocial as they go into adolescence, but these are quite unusual and there is very little work looking are they are and what they look like etc. However, research shows that most conduct disordered boys with early onset do continue to demonstrate some conduct problems into adulthood (Lahey et al., 1995). This might not result in a diagnosis of antisocial personality disorder but it might translate into negative life events (poor relationships, jobs etc.). CD is massively heterogeneous (Rutter, 2008), there is no one way of becoming antisocial. There are lots of different ways to subtype. DSM subtypes by age. Sheila Hogins proposes subtypes on the presence of co-morbid psychosis/substance abuse. Presence of callous-unemotional style are another type of subs typing. All may have different bases and mechanisms for understanding antisocial behaviour but they are not excessive of each other either. CU traits and psychosis may offer a way if delinerating out different types of children with behavioural problems. Its possible to use or many of these subtypes. Subtypes are important when considering how to implement successful interventions that will be effective.

Question 9

For a long time the DSM has categorised CD on the basis of early and adolescent-onset.

Kim-Cohen et al., 2005
Moffitt (2003

Answer 9

For a long time the DSM has categorised CD on the basis of early and adolescent-onset. Early onset symptoms were before 10yrs, these children are the ones that are thought to have the worse outcomes, typically increases in rate and severity throughout childhood and into adolescence (Kim-Cohen et al., 2005). Whereas adolescent onset proposed to be an extreme of the normative adolescent process of asserting independence. Moffitt (2003) considered this behaviour to have origins may be in social processes (peer group, monitoring from parents, etc.). The age of onset is not always reliable, however its predictive validity is quite good, in that we know there are likely to poorer outcomes for the children with problem behaviour earlier on in childhood. Child that stabbed someone: not adolescent onset, problems before that hadn’t brought the child to the attention of criminal or justice services. Early onset probably requires even more sub-typing in order to determine what will be affective in terms of intervention. The DSM-5 has a new qualifier and divides CD into two sub-categories children that show a lack of remorse or guilt for bad behaviour and callous lack of empathy. These two things map on to all the research work that has even done with CU traits or early psychopathic traits. Limited prosocial tendencies is the nicest way of saying a child has severe difficulties with empathy and behaving in a non-psychopathic way.

Question 10

Broadly indexing callous- unemotional traits (CU) is Psychopathy in adults Precursors of psychopathy in children.

(Hart & Hare, 1997; Frick & White, 2008).
Frick et al., 1994

Answer 10

Broadly indexing callous- unemotional traits (CU) is Psychopathy in adults Precursors of psychopathy in children. Describes a minority of children with antisocial behaviour but these children are likely to do the most harm and have the most serve behavioural problems (Hart & Hare, 1997; Frick & White, 2008).

In the early 1990’s, Paul Frick and extended the concept to adult psychopathy to children and included measurement of CU, narcissistic and impulsive characteristics (Frick et al., 1994). The key CU characteristics are also central to the concept of psychopathy in adults. CU traits include a lack of guilt, absence of emotional empathy and shallow affect (poverty of expressive emotions: non-emotional, flat, difficult to judge interns of emotions, doesn’t look to be guilty when they do something wrong).

Question 11

There are two ways of measuring CU,

Frick & Hare, 2001
Frick, 2003

Answer 11

There are two ways of measuring CU, the Anti Social Process Screening Device APSD (Frick & Hare, 2001). It has three factor structure: looking directly at CU traits, impulsive behaviour and narcissistic behaviour. (CU: Concerned about schoolwork, Does not show feelings or emotions, Feels bad/guilty when s/he does something wrong; Impulsivity: Blames others for his/ her mistakes, Gets bored easily, Engages in risky or dangerous behaviour; Narcissism: Emotions seem shallow and not genuine, Can be charming at times, but in ways that seem superficial or insincere, Brags excessively about his/her abilities, accomplishments or possessions). These three things are an analogy to adult psychopathy as seen in children. Questionnaire can be filled in by teacher parents and the child. There are about 24 questions.

Or the Inventory of Callous-Unemotional traits (Frick, 2003) which is a 24-item scale based on CU subscale of APSD, which has a bit more variability to investigate CU traits. It has got good internal consistency (α = .77, Essau et al., 2006) and construct validity has been demonstrated (Kimonis et al., 2008), which is in fact better than the APSD. This scale is looking at: Does not care who he/she hurts to get what he/she wants, Seems very cold and uncaring, Does not like to put the time into doing things well, The feelings of others are unimportant to him/her. These children are not socially motivated like the rest of the population.

Question 12

We know that behaviourally these children will have the worst outcomes and more severe behavioural problems than other children with CP.

(Frick & White, 2008; Viding, Jones et al., 2008).

Answer 12

We know that behaviourally these children will have the worst outcomes and more severe behavioural problems than other children with CP. More likely that their outcomes will persist for longer and have long term difficulties than other children with CP, these children are more genetically vulnerable to behavioural problems than other children with CP (Frick & White, 2008; Viding, Jones et al., 2008).

Question 13

In an extremes analysis, conducted on the the TEDS sample of children at 9 years of age.

. (Viding, Jones et al., 2008).

Answer 13

In an extremes analysis, conducted on the the TEDS sample of children at 9 years of age. 80% of the TEDS sample were not of interest. Instead the top 10% of children with high CU traits and the bottom 10% of children with low CU traits were documented. This is a population sample so these children were not in that much trouble. In the high CU group, the majority of influence on antisocial behaviour is genetic. The opposite was true for the low CU children who are empathic and feel guilty for their behaviour. Therefore the environment is more influential for these children (likely to be parenting, supervision, neighbourhood, peer group, inhibition, anxious). Children with high CU traits are not anxious/associated with lower anxiety levels. A growing evidence base indicates children with CP/CU+ traits are more genetically vulnerable to behavioural problems than other children with CP. Therefore, treating children with CD the same is a pointless endeavour. (Viding, Jones et al., 2008).

Question 14

No epidemiological data is currently available. Based on adult APSD & Psychopathy diagnoses, prevalence of CP/CU+ estimated to be 0.75% (Blair, Mitchell, & Blair, 2005); Increased severity of antisocial behaviour (Dadds, Fraser, Frost & Hawes, 2005; Frick & Marsee, 2006); Lower anxiety levels (Dolan & Rennie, 2007; Frick et al., 1999); Loeber et al. (2002): CU traits one of the best predictors of later, persistent AB; Dadds et al. (2005): CU traits predict cruelty to animals in young children.

Answer 14

No epidemiological data is currently available. Based on adult APSD & Psychopathy diagnoses, prevalence of CP/CU+ estimated to be 0.75% (Blair, Mitchell, & Blair, 2005); Increased severity of antisocial behaviour (Dadds, Fraser, Frost & Hawes, 2005; Frick & Marsee, 2006); Lower anxiety levels (Dolan & Rennie, 2007; Frick et al., 1999); Loeber et al. (2002): CU traits one of the best predictors of later, persistent AB; Dadds et al. (2005): CU traits predict cruelty to animals in young children.

Question 15

This area of research on started in the 1990’s and therefore, its only now the longitudinal data is looking at the outcome of children with high CU traits.

Baskin-Sommers et al.,(2015)

Piquero et al (2012):

Muratori et al.,(2016):

Answer 15

This area of research on started in the 1990’s and therefore, its only now the longitudinal data is looking at the outcome of children with high CU traits. Relatively few opportunities for long-term follow up of CU, but more outcome studies in pipeline. Baskin-Sommers et al.,(2015): CU is a strong predictor of adolescent substance use and violence; Piquero et al (2012): High youth psychopathy linked with future offending; Muratori et al.,(2016): CU traits associated with more severe behavioural disorders and substances use in adolescence for children with disruptive behaviour disorders.

Question 16

Psychopaths like drugs because its fun. This is another thing to consider when thinking about interventions for these kinds of disorders.

Answer 16

Psychopaths like drugs because its fun. This is another thing to consider when thinking about interventions for these kinds of disorders. They are not doing it because they are social anxious. They like the feeling of being able to risk take and the heightened arousal that people get from substance use. There can also be some interesting outcomes for children who take loads of drugs e.g. becoming highly anxious and agoraphobic. Thus CD if further complicated due to the high rate of substance use in children as young as 8 years of age.

Question 17

It’s unlikely that an adult psychopath will be cured. However, children are still quite

Answer 17

It’s unlikely that an adult psychopath will be cured. However, children are still quite plastic and thus there is much more scope for intervention. Some studies suggest that CU traits may not be highly stable over time (parent reports).

Question 18

Natalie Fontaine et al (2010) using the TED sample were they split kids into four groups:

Answer 18

Natalie Fontaine et al (2010) using the TED sample were they split kids into four groups: Children with high CD and CU, children who increased in their report in CU over time, children who decreased in their report in CU over time and children who were low CU the whole time. There is less than 10% of children who were high CU across each time point. The vast majority 80% were low CU for the whole time. Looked at 8, 9, 12 years of age in the teds sample. There was these odd two subgroups around 10% each that should this fluctuation of CU traits across time. These are reports from parents and teachers across a few different time points and some children who were increasing and some were decreasing over time. This is quite curious. It might relate to things like parental supervision and warmth or even peer group but it is not clear why this happens.

Question 19

Similarly in a treatment study that Dadds & Hawes (2007) conducted, where they had a group of children whose parents did parenting training,

Answer 19

Similarly in a treatment study that Dadds & Hawes (2007) conducted, where they had a group of children whose parents did parenting training, about half of the highest scoring CU children dropped to below the median in an intervention study. It might be that the parents felt more able to deal with the children, so they rated them differently but there was no actual change in behaviour, instead the parent just felt like they knew what to do. Or there was a chance in child behaviour. This is unsure. These studies offer hope for timely interventions targeted toward reducing CU traits in children with CP.

Question 20

The neuropsychological profiles of antisocial behaviour (Conduct Disorder and Callous-unemotional traits).

Answer 20

The neuropsychological profiles of antisocial behaviour (Conduct Disorder and Callous-unemotional traits). Traditionally, CU hasn’t been associated with IQ deficits. The stereotypical model of a psychopath is somebody who is very verbally able, who is really good at tricking people. Its more likely that lots of kids who have these CU traits perform more poorly on IQ tests than their peers do and there are a couple of good reason for this 1) they have difficulties with working memory and 2) its hard to well in an IQ test if you don’t do school well. IQ involves a child having crystallised intelligence, vocabulary and the development of abstract concepts and understanding of the world. A child that rebels against school will not have an opportunity to build up this knowledge. Often there are children do poorly on certain subtests because their ability to access curriculum has been poor. Often these children like to show off/demonstrate their brilliance and they get a lot of validation.

Question 21

One recent study on 4713 nine-year olds reports that narcissism is positively associated

(Fontaine et al., 2008).

Answer 21

One recent study on 4713 nine-year olds reports that narcissism is positively associated with verbal and non-verbal abilities (even after controlling for CP and ADHD symptoms). CU traits and Impulsivity were negatively associated with verbal and nonverbal ability, but these associations did not hold after controlling for CP and ADHD symptoms (Fontaine et al., 2008).

Question 22

Another confounding factor that relates to the comorbid conditions is impulsivity and inhibition problems which are negatively associated with

Answer 22

Another confounding factor that relates to the comorbid conditions is impulsivity and inhibition problems which are negatively associated with verbal and non-verbal abilities. ADHD is probably a cofounding factor. Executive Functioning covers a broad range of cognitive abilities that control and regulate other abilities and behaviours (decision-making - planning- inhibition- impulse control- mental flexibility). EF deficits have long been implicated in antisocial behaviour.

Question 23

Most people that are in the prison system have

Patterson & Newman, 1993

Seguin, 2004

Answer 23

Most people that are in the prison system have poor EF, these people display disinhibited, impulsive behaviour, high levels of risk taking and do not seem to learn from mistakes (Patterson & Newman, 1993). These patterns of behaviour mirror those seen in individuals who have suffered ventral medial prefrontal cortex vmPFC damage. Therefore, does frontal lobe dysfunction underlie antisocial behaviour? (Seguin, 2004).

Question 24

Adrian Raine et al (1998) has done quite a lot of work in brain imaging of people with antisocial behavioural problems.

Answer 24

Adrian Raine et al (1998) has done quite a lot of work in brain imaging of people with antisocial behavioural problems. He’s done some nice work with adult offenders, in those that have committed an offence in an emotional and impulsive kind of way (e.g. somebody who had been slighted in the heat of the moment usually). These people have decreased prefrontal activity and increased sub-cortical activity (including the amygdala). Essentially, they are very emotional, their brains are working in a highly changed way in terms of emotion processing and not down regulating that effectively. Cold-blooded murderers (psychopaths) however, showed more normal prefrontal activity.

Question 25

For some people with antisocial personality disorders, these are people for whom antisocial behaviours are a complete way of life. Raine et al (2002) showed

Raine et al (2007)

Answer 25

For some people with antisocial personality disorders, these are people for whom antisocial behaviours are a complete way of life. Raine et al (2002) showed that people with antisocial personality disorder had an 11% reduction in volume in the gray matter in the prefrontal cortex. Raine et al (2007) also showed white matter differences in the prefrontal area in pathological liars (which is a different form of antisocial behaviour). There are clearly some important prefrontal cortex differences amongst these sorts of individuals. Therefore, to is likely that these issues have come from very early on in childhood.

Question 26

To grow up with impairments relating to vmPFC (vmPFC encompasses orbitofrontal and medialfrontal cortex) means that there may be impairments with

Bechara et al., 1994

Schoenbaum & Roesch 2005

Bechara et al., 2000

Answer 26

To grow up with impairments relating to vmPFC (vmPFC encompasses orbitofrontal and medialfrontal cortex) means that there may be impairments with decision making e.g. risks behaviour (Bechara et al., 1994). Therefore when information come from the amygdala to start to make a decision and the hippocampus which should remind a person not to make the same mistake, these processes aren’t really forming part of the design making process appropriately/adequately. Consider involvement of OFC in emotion processing (with amygdala). The amygdala feeds forward reinforcement information associated with stimuli to vmPFC, which then represents this outcome information (Schoenbaum & Roesch 2005). Deficits in emotion processing are also associated to impaired decision making, reflected in behaviours such as risk taking and impulsive behaviours (Bechara et al., 2000).

Question 27

Individuals with chronic antisocial behaviour do not learn from punishment, which is especially true for psychopaths. Individuals with psychopathy are impaired in both

Newman et al. 1987; Mitchell et al. 2002; Budhani & Blair 2005; Budhani et al. 2006

Answer 27

Individuals with chronic antisocial behaviour do not learn from punishment, which is especially true for psychopaths. Individuals with psychopathy are impaired in both behavioural extinction and reversal learning (Newman et al. 1987; Mitchell et al. 2002; Budhani & Blair 2005; Budhani et al. 2006). An fMRI study of reversal learning suggests that healthy adults showed a reduced BOLD response within vmPFC to punished incorrect reversal phases responses relative to correct responses.

A similar study carried out with children with CU traits and comparison children reported that: the comparison children also showed significant reductions in BOLD responses in vmPFC to punished incorrect reversal responses relative to correct responses. The children with CU did not.

Question 28

Developmental consequences of vmPFC dysfunction:

Answer 28

Developmental consequences of vmPFC dysfunction: Impairment in vmPFC functioning means that individuals with psychopathy will show impaired decision making contribute to disordered lifestyle and increase risk for drug abuse.

Because vmPFC is important for successful decision making, dysfunction will increase the probability that individuals with the disorder will make less than optimal decisions when attempting to achieve their goals increase the risk for frustration and potentially frustration- based reactive aggression.

Question 29

Memory is really interesting to think about in relation to antisocial behaviour.

Answer 29

Memory is really interesting to think about in relation to antisocial behaviour. Fairly few studies have looked at it and the reason is in childhood memory tests are boring and incredibly middle class (e.g. I’m going to tell you a story about a boy and his doggy and then ask you some questions about it in an hour). When the child was in fact not listening because the story was boring and un-engaging, the child knows they won’t be good at it so they are not even trying. Therefore to test memory in AB, we need to get more creative/inventive.

Question 30

From the work that has been done, physically aggressive boys have poorer working memory than non-aggressive boys (Seguin et al., 1999)

van Goozen et al, 2004
Dolan & Fullam, 2010

Answer 30

From the work that has been done, physically aggressive boys have poorer working memory than non-aggressive boys (Seguin et al., 1999) but consider studies that link working memory to IQ (see work by Tracey Alloway). Result held after controlling for IQ and ADHD symptoms. Other studies found no deficits in working memory for children with ODD and ODD/ADHD (van Goozen et al, 2004). Considering what is already known about the brain abnormality of psychopaths. A recent study suggests that recall accuracy for emotional events is poorer in adolescents with high levels of CU traits (Dolan & Fullam, 2010). This is demonstrated by the normal increase in saliency of emotionally changed events for TD people. The amygdala is critically involved in emotion saliency and activates to help encode more information. This enhanced memory does not happen for children with high levels of CU traits.

Question 31

Therefore, antisocial behaviour/ children with CD and violence have been associated with structural and functional brain abnormalities

Davidson, Putnam & Larson, 2000

Kiehl et al., 2001; Yang et al., 2005; Marsh et al., 2008; Jones et al., 2009; De Brito et al., 2009

Answer 31

Therefore, antisocial behaviour/ children with CD and violence have been associated with structural and functional brain abnormalities in several brain areas associated with perception and regulation of emotions (Davidson, Putnam & Larson, 2000). In antisocial adults and children, regions such as OFC, ACC and amygdala have been shown to have structural and functional abnormalities (Kiehl et al., 2001; Yang et al., 2005; Marsh et al., 2008; Jones et al., 2009; De Brito et al., 2009).

Question 32

Hostile Attribution bias by Ken Dodge proposed this social-cognitive mechanism for (aggressive behaviour)

Dodge et al. (1990), Weiss et al., (1992), Hill et al (2008).

Answer 32

Hostile Attribution bias by Ken Dodge proposed this social-cognitive mechanism for (aggressive behaviour) understanding antisocial behaviour which is essentially if the world has taught a child that people are out to get them, then thats how they should behave. This is quite an adaptive response. Children are looking out for cues in the environment that aren’t friendly. These are the people that ask a person in a bar what they are looking at when in fact they are looking at nothing, they are looking out for danger in the environment. If these children were at home with aggressive parents and they don’t know when the next hit around the head was coming, its in the child interest to look out for it. A Hostile Attribution is characterised by hypervigilent selective attention to hostile cues, hostile attributions to others’ ambiguous behaviour, favourable evaluations of the likely consequences of antisocial behaviour and a tendency to remember aggressive/hostile acts. Longitudinal work suggests that these biases develop partly as a consequence of adverse early life experiences Dodge et al. (1990), Weiss et al., (1992), Hill et al (2008).

Question 33

The Hostile Attribution becomes a self fulfilling cycle

Evans et al (2002)

Answer 33

The Hostile Attribution becomes a self fulfilling cycle, a person that behave this way will evoke the same response from other people. Hostile Attributions are also associated with impaired peer relationships and reactive aggression. Children who hold hostile attributions are typically poor at social problem-solving and repeated social failures may bring about the development of negative self- perceptions of competence. Predicts a cycle of hostile attribution leading to aggressive behaviours that decrease opportunities for successful social interactions. Evans et al (2002) suggest that hostile attributions may interfere with normal empathy functioning in a different way to psychopathy (the need to show someone who’s boss who has wronged them).

Question 34

Processing other peoples’ emotions. People that are hypervigilent (history of physical abuse).

Pollak
(Blair & Viding, 2008; Munoz, 2009).

Answer 34

Processing other peoples’ emotions. People that are hypervigilent (history of physical abuse). If these children are shown faces, some that are ambiguous, others are very clear in what emotions they are. If these children who have experienced a lot of aggression their lives are more likely to recognise angry faces (Pollak) even in the ambiguous faces. Children with high CU traits are really poor at recognising or processing stress emotions (fear and sadness in particular), this is true for visual stimuli, vocal stimuli and body postures as well. They are not recognising fear in the environment (Blair & Viding, 2008; Munoz, 2009).

Question 35

There are deficits in empathy in CD. Zahn-Waxler et al (2009) examined effects of distress on empathic concern in preschoolers

Answer 35

There are deficits in empathy in CD. Zahn-Waxler et al (2009) examined effects of distress on empathic concern in preschoolers to see who will behave in a pro-social way in the situation of another person being injured. They found those at moderate-high risk of developing CD showed less engagement with the person in distress. There are two probable reasons for these findings, first is a lack of empathy. Its also possible that these children don’t have a working model of what to do when someone is hurt. Or they recognise stress but find it really overwhelming (often the case with people with ASD), these people can’t dampen down their emotional response to somebody else distress. However, if a person is empathic, they should be able to respond in an appropriate way (recognise the stress of another, have own emotional response but able to regulate own response in order to act appropriately). Therefore its likely that there are a subgroup of children who look like they develop CD yet they have empathy but its just faulty without the correct regulation strategies.

Question 36

de Wied et al (2009) suggested that boys with behavioural problems did not lack empathy, but had decreased empathic responses to

Answer 36

de Wied et al (2009) suggested that boys with behavioural problems did not lack empathy, but had decreased empathic responses to sad and distressed children compared to controls. Due the fact there has been no subgrouping of CD/CU traits within these studies its difficult to hypothesise about whats driving the outcomes.

Question 37

Hughes & Ensor (2007) found early Theory of Mind skills have been shown to predict later behavioural problems,

Answer 37

Hughes & Ensor (2007) found early Theory of Mind skills have been shown to predict later behavioural problems, irrespective of verbal IQ etc. They developed this theory of nasty minds which strongly relates to the hostile attribution bias. Children that have behavioural problems will tend to attribute negative thought and feelings towards people even in ambiguous situations. In a problem solving task with a small child, they will take the aggressive problem solving solution (there is a dinosaur coming, what should we do? Kill the dinosaur!). Thus theres an inflexibility in problem solving and a difficulty in understanding other people thoughts and perspectives for children with behavioural problems.

Question 38

Empathy deficits are pretty much key to psychopathology, Hervey Cleckley wrote the first book on psychopathology called the mask of sanity

Answer 38

Empathy deficits are pretty much key to psychopathology, Hervey Cleckley wrote the first book on psychopathology called the mask of sanity which is a collection of case studies of people who are psychopathic, summed it up very neatly he suggested that not having the ability to know how others feel or to feel anything comparable about it. Having that complete lack of emotional association with another person. Therefore, we can’t understand what its like for them. Cleckley: “He has no ability to know how others feel… or to feel subjectively anything comparable about the situation”.

PCL-R (Hare, 2003) “callousness and lack of empathy”
APSD (Frick & Hare, 2001) “concern about the feelings of others”

Question 39

A question that clinicians ask a lot is, is psychopathy is a disorder of empathy and so is ASD,

Hare, 2003

Hippler & Klipecra, 2003

Answer 39

A question that clinicians ask a lot is, is psychopathy is a disorder of empathy and so is ASD, but they are clearly not the same thing, psychopaths do not have ASD (usually). Empathy is an unsatisfactory term, its a lay term which has been appropriated without considering what it means. The ASD community have appropriated empathy to mean ToM deficit and people that study psychopathy have appropriated empathy to mean having a emotional response based on somebody else emotional situation.

Psychopathy is a disorder of empathy (Hare, 2003) -  profound disturbance in the appropriate ‘empathic’ response to the distress of another. ASD is also often referred to as an empathy disorder -  But ASD not associated with increased criminality at
population level (Hippler & Klipecra, 2003). Empathy deficit cognitive (Theory of Mind), not affective? Several outstanding research questions.

Question 40

Using the Victim Suffering paradigm previously used by Pardini et al (2003).
Differences of empathy in children with behavioural problems with and without CU traits, children with ASD and TD children.

Answer 40

Using the Victim Suffering paradigm previously used by Pardini et al (2003).
Differences of empathy in children with behavioural problems with and without CU traits, children with ASD and TD children. First addressed was children own feelings of emotions, the children were given a little scenario that was either relating to something disgusting, embarrassing, scary or something that would usually make them feel guilty. The children were asked to report how much of the emotion they would feel in this scenario. The high CU group reported feeling much less scared and guilty in most circumstances. Therefore, not only are they poor at recognising fear, they also report not feeling it much themselves either. They also used the paradigm where they asked children to imagine a situation where there is something happening which is a little frustrating and they behave in an aggressive way to get over it “You are really thirsty and need a drink of water. Another boy is drinking slowly at the water fountain and you are thinking about pushing him out of the way so you can get a drink”. In the first section the children were asked what they thought would happen as a result this, will you get into trouble, will you get what you want, will you make that person feel bad, will you make your self feel bad, will you show them who’s boss. Then they were asked: How much do you care about… getting the tangible ‘reward’ as a result of your behaviour, being punished for your behaviour, making the victim feel bad as a result of your behaviour, making yourself feel bad as a result of your action, gaining a sense of dominance (showing your peer ‘who’s boss’) as a result of their actions. In the findings, the expectation section is similar to ToM and the second stage was more affective. The results found that everyone was able to say/understand that if they hurt someone they would feel bad (no group difference).

For both: How much would you care if you felt bad or someone else felt bad? The high CU group in comparison to the other groups do not really care. Interesting, the CD with CU traits never differ from controls on any type of emotion processing task that we did. The psychopaths know that they don’t care, they are also really good at ToM. In a basic ToM task, the first and second order ToM: theres a boy, he has some chocolate, he puts it in the fridge, his sister knows he put in the fridge, he goes and takes it out and hides it. Where does she think it is? She thinks its in the fridge. But on no, she saw him, so where does he think that she thinks that it is? He thinks, that she’s thinks it’s in the fridge because he doesn’t know that she saw him. This study was done with 11-12 year olds, its expected that the ASD group to do be able to do 1st and 2nd order ToM by this time, these are bright kids and they can usually problem solve around ToM problems by this stage. In fact the ASD group did not do this, nor did the control group. The high CU group who had the lowest IQ of the groups too, scored at absolute ceiling, their ToM is impeccable. They can follow other peoples thought processes, they just don’t care about them.

Question 41

Using the Victim Suffering paradigm previously used by Pardini et al (2003).

Conclusions: There is a dissociation between the type of empathy deficit in children with CU and children with ASD.

Blair, 2005

Schwenck et al (2012, JCPP).

Holmqvist, 2008

Pardini, Lochman & Frick, 2003

(Dadds et al., 2009).

Answer 41

Conclusions: There is a dissociation between the type of empathy deficit in children with CU and children with ASD. Children with CP/CU+ have difficulties attributing feelings of fear and guilt to themselves, Emotion processing and affective empathy deficits were found to be unique to children with CP/CU+, no deficits were observed for children with CP/ CU-, or children with ASD, Cognitive empathy (ToM) deficits were found to be unique to children with ASD, no deficits were observed for children with CP/CU+ or CP/CU-. The data supports the theory that cognitive and affective empathy are dissociable abilities and that children with CP/CU+ and ASD suffer from distinct forms of empathy deficit (Blair, 2005). These findings were replicated by Schwenck et al (2012, JCPP). Further research in empathy and CU have found negative relationship between PCL-R scores and self-report empathy (Holmqvist, 2008). Negative relationship between ‘Empathic Concern’ subscale and CU traits (Pardini, Lochman & Frick, 2003). However, the relationship between emapthy and CU may be mediated by gender and age (Dadds et al., 2009).

Question 42

What we should be interested in is how did those deficits develop. Its likely that they happen very early on and there is a kind of cascade affect which happens from the first days of a child’s life.

Kiehl et al., 2001

Birbaumer et al., 2005

Deeley et al., 2006

Answer 42

What we should be interested in is how did those deficits develop. Its likely that they happen very early on and there is a kind of cascade affect which happens from the first days of a child’s life. A person who fails to attend to emotional stimuli, will not learn about the valiance or the value of it. Failure to attend to emotional stimuli may be a core characteristic of ‘cold’ varieties of aggressive and antisocial behaviour. Failure to attend to the eyes of attachment figures may be a critical feature of CU traits emerging very early and leading to cascading errors in the development of empathy and conscience. Early damage to the amygdala leads to cascading errors through the neural systems responsible for the development of higher-order systems underlying empathy and theory of mind. If the amygdala does not develop in the same way that other peoples does, they are not getting a surge of, this information is important when they see emotion information happen. Therefore, they are not going to develop moral and emotional understanding or empathy in the same way that other people are. There is a reduced amygdala response during any emotion task with adult psychopaths. Reduced amygdala response during emotion memory task compared with incarcerated controls (Kiehl et al., 2001). Reduced amygdala reactivity during fear conditioning compared with controls matched for age and education (Birbaumer et al., 2005). Reduced visual cortex activation (amygdala proxy) in incarcerated psychopaths (Deeley et al., 2006). Most of this work was done in prisons: adult psychopaths really like taking drugs and thus how do we know that these brain differences aren’t simply the result of substance use.

Question 43

There are also robust data now from children. Boys with CU+ have hypo activation amygdala response to fearful faces compared with typically developing children. Jones et al (2009; AJP) Marsh et al (2008; AJP) Viding et al (2012; AJP) Adolphs, 2007; Blair & Viding, 2008.

Answer 43

There are also robust data now from children. Boys with CU+ have hypo activation amygdala response to fearful faces compared with typically developing children. Jones et al (2009; AJP) Marsh et al (2008; AJP) Viding et al (2012; AJP) Adolphs, 2007; Blair & Viding, 2008.

Therefore it seems that this amygdala deficit is fairly central to psychopathy. The amygdala mediates conditioned emotional responses, also important for perception of emotional expressions in humans. Patients with amygdala damage have poor conditioned emotional responses and poor fear recognition and so do adult psychopaths and children with CP/CU+.

A toddler who behaves in aggressive way might make another person cry, or a parent might do an exaggerated sad face. The child usually pays attention to the client face which will understand what it feels like and process an emotional response to that, its not a nice one therefore they to not this thing again and make this situation right. Crudely, this is how most moral development starts, if a child in not paying attention in the first place, children with CU traits and their amygdala damage means they don’t pay attention to the right parts of the face.

Question 44

Amygdala and eyes:

Dadds et al., 2006

Dadds et al., 2008

Answer 44

Amygdala and eyes: Amygdala damage leads to attentional neglect of the eye region of the face. Low amygdala reactivity in children with CP/CU+ may reflect their failure to focus on the eye region of the face (Dadds et al., 2006). When told to look at the eyes, the CU children are as good as everyone else. Dadds et al., 2008 also supported this in an eye tracking study when the high CU children were looking at the mouth region. A child that does not learn by witnessing somebody else distress, how do they develop empathy across the life span.

Question 45

Developmental consequences of amygdala dysfunction:

Answer 45

Developmental consequences of amygdala dysfunction: Amygdala is crucial for stimulus–reinforcement learning and responding to emotional expressions. particularly fearful expressions: important initiators of S-R learning. Individuals with psychopathy show impairment in S-R learning and responding to fearful and sad expressions. this impairment may drive much of the syndrome of psychopathy, S-R learning is crucial for socialization. Learning following the witnessing of another’s distress is diminished - leads to reduced empathy generally.

Question 46

Social-Emotional development in CU:

Answer 46

Social-Emotional development in CU: What we know from older child and adult studies Poor fear/distress recognition, Poor affective empathy, Likely to be associated with hypo-functioning amygdala.
How did those deficits develop? Failure to attend to emotional stimuli may be a core characteristic of ‘cold’ varieties of aggressive and antisocial behaviour, Failure to attend to the eyes of attachment figures may be a critical feature of CU traits emerging very early and leading to cascading errors in the development of empathy and conscience. Early damage to the amygdala leads to cascading errors through the neural systems responsible for the development of higher-order systems underlying empathy and theory of mind.

Question 47

Eye love you (Dadds et al., 2012): In an illustrative task with

Answer 47

Eye love you (Dadds et al., 2012): In an illustrative task with 24 children (4-8yrs), 12 with ODD & 12 comparison. Some of the children in ODD also have quite high levels of CU traits. No demographic differences. Statistically sig. differences on all SDQ subscales and CU component of APSD (ODD group = greater difficulties). Exp (blind to status) in an adjacent room that provided both videotape and two-way mirror visual and audio access to the playroom. These children have come into the lab and have completed many task whilst there and at this point they are in a room with a parent and they have been doing some pre play for a while. After 30m of free play and shared conversation the mother was previously instructed to find a natural break in what they are doing and say “do you know what, we’ve had a really nice time today, you’re doing well and we are having a really nice time together. I really love you!” In terns of the three groups, there was no difference (eye contact, physical and verbal affection) in how the mother interacts with her child. However, there is a difference in what happens in return, the CU kids gave less eye contact, less physical affection and less verbal affection too. A child that gives no emotion back will be quite hard to parent.

Question 48

People and the government are worried about early experiences.

Answer 48

People and the government are worried about early experiences. One thing that has been though about for a long time is the effect of smoking during pregnancy on a child. For a long time it was believed that if a person smoked, there was going to be bad outcomes for the child. Anita Thackwell suggested that actually maybe it was not the smoking per se, it was simply if you’re a person willing to smoke during pregnancy, even through you know all the health warnings, then maybe your child is likely to end up a bit more antisocial because you are giving them a genetic predisposition to behaving in a way which is socially accepted as antisocial.

Question 49

Gaysina et al (2013) compared children from 3 different groups which enabled her to pull apart the genetic environmental influences,

Answer 49

Gaysina et al (2013) compared children from 3 different groups which enabled her to pull apart the genetic environmental influences, segregated the genetic and environmental influences associated with maternal smoking using a design comparing children born of genetically related parents, with adopted children, and with children conceived using donor eggs via IVF (mother is not genetically related to the child). In all the groups maternal smoking was linked with increased child conduct problems when children were raised by genetically-related and unrelated mothers. Therefore highlighting the effects of smoking/genes on CD.

Question 50

Hanson et al (2015) investigated brain differences in children who had experienced early a) physical abuse; 2) early neglect; 3) social and economic deprivation or 4) none of these.

Answer 50

Hanson et al (2015) investigated brain differences in children who had experienced early a) physical abuse; 2) early neglect; 3) social and economic deprivation or 4) none of these. All problematic early life experiences were associated with smaller amygdala volume. Physical abuse and extreme socioeconomic deprivation were associated with smaller hippocampal volume. Smaller brain volumes were associated with greater stress, and poorer behavioural outcomes. It may be that disruption to brain development in these areas provides a mechanism for poorer outcomes It might be that during these early years, if a child suffers a lot of trauma, deprivation and a lot of hardship, this will have a result on the development of the brain which is likely to have some behavioural outcomes. This study looked at pre 5 years of age.

Abuse that happens when a child is preverbal (1 year old) effects a differs brain region than abuse at 4 years old.

Question 51

Pesalich et al (2012) evidence to suggest that the affective quality of parent-child relationships may be particularly important for the socialisation of antisocial children elevated on CU traits.

Answer 51

Pesalich et al (2012) evidence to suggest that the affective quality of parent-child relationships may be particularly important for the socialisation of antisocial children elevated on CU traits. Secure parent- child attachment relationship provides a more effective alternative to parental discipline for moral development in children with CU-type temperament characteristics. Parental warm this negatively associated with anti-social behaviour in children with high rather than low CU traits. Constantly role modelling good behaviour for better outcomes. Its hard to make a child with high CU traits empathic but this is okay.

60 boys (3-9 years) met criteria for CD or ODD at clinic and tested attachment (Manchester-Child Attachment Story Task). Those with elevated CU traits were more likely to have disorganised representations of parent-child attachment relationships; independent of the effects of age and caregivers’ level of education. Lack of organisation and coherence in attachment schemas appears to be most significant for elevated CU traits in children with conduct problems.

Question 52

There is also interesting work on the effect of early maternal distress which should lead into a policy debate in how to support mothers that are having a tough time.

Choe et al (2013)

Answer 52

There is also interesting work on the effect of early maternal distress which should lead into a policy debate in how to support mothers that are having a tough time. If a person is really distressed as a mother in the early years, they are less likely to be emotionally available for your child. They are less likely to use inductive discipline strategies which are those which are going to help a child understand where they went wrong (we don’t do this because its unsafe and inappropriate etc.). Inductive discipline is about demonstrating concepts and subtractions rather than just saying no. These kinds of things are associated with poorer emotion regulation skills are 3 years old and poorer emotion regulation skills are 3 years old are associated with greater behavioural difficulties later on in childhood. Working on the premise that maternal distress compromises parenting and child’s self-regulation skills. Elevated maternal distress in early years was associated with less maternal warmth, less inductive discipline and poorer effortful control at 3yo. Less effortful control at 3years associated with greater externalizing difficulties at 6 and 10 years (Choe et al (2013). Therefore, resources should be pushed to help make things better for these mothers.

Question 53

Harsh punishment may elicit high levels of arousal, making it difficult for children to internalize parental messages about prosocial behaviour (Pardini et al., 2007).

Kochanska, 1997

Hawes & Dadds, 2005

Answer 53

Harsh punishment may elicit high levels of arousal, making it difficult for children to internalize parental messages about prosocial behaviour (Pardini et al., 2007). Parental warmth and responsiveness may protect against the development of AB by promoting empathy and prosociality, particularly in children with fearless temperaments (Kochanska, 1997). Harsh punishment reinforces the message that this is what we do to get what we want. Its important to promote warmth and role model.

Common Strategies: Time Out, Ignoring/ Distracting from unwanted behaviour, Setting boundaries. Increase co-operation, Praise and Incentives. Building social competence, Joint play, promoting positive Parent-Child relationships.
Use of punishment: Time out is a typical and often recommended form of punishment, Time-out is a less effective strategy for children with elevated CU traits, They also show less negative affect when used Hawes & Dadds, 2005

Question 54

Hawes & Dadds (2007) Approximately half of the children considered high CU pre-treatment were rated as high CU at post-treatment.

Hawes, Dadds, Frost & Hasking (2011; JCCAP)

Answer 54

Hawes & Dadds (2007) Approximately half of the children considered high CU pre-treatment were rated as high CU at post-treatment. Although CU and CP followed the same trajectories, scores on these factors were predicted by different variables. Group with the most high-stable CU traits showed least improvement in an-social behaviour, and least responsivity to ‘-me-out’.

Question 55

Hawes et al (2011; JCCAP) CU traits predicted change in three out of the five domains of parenting examined:

Answer 55

Intervention: Hawes, Dadds, Frost & Hasking (2011; JCCAP) Examined the relationship between CU traits and parenting practices in 3-10 years olds over one year, Parenting practices: monitoring/supervision, inconsistent discipline, physical punishment, positive parenting, parental involvement, Reported a dynamic relationship between parenting and CU.

Hawes et al (2011; JCCAP) CU traits predicted change in three out of the five domains of parenting examined: corporal punishment, inconsistent discipline, and parental involvement. They were associated within creased levels of inconsistent discipline irrespective of child age and sex, increased levels of physical punishment among older children only, CU traits were associated with reduced levels of parental
involvement in older boys and younger girls. Positive parenting and parental involvement predicted change in CU traits in both boys and girls, this change was associated predominantly with positive parenting in girls and parental involvement in boys.

Question 56

Functional family therapy is a good way of thinking about managing antisocial behaviour, its very expensive, its quite burdensome but it has good results. White et al (2012) looked at this in

Answer 56

Functional family therapy is a good way of thinking about managing antisocial behaviour, its very expensive, its quite burdensome but it has good results. White et al (2012) looked at this in relation to CU traits and noticed that if the families remain involved (because there is quite a big drop) there is good outcomes in terms of improvement for something like functional family therapy. 134 detained youths in functional family therapy programme, CU traits associated with poorer behavioural, emotional, and social adjustment prior to treatment. BUT! They were also associated with greater improvements in adjustment.

Question 57

Salukis et al. (2012) has done something nice with young offenders which has been about using cognitive behaviour training, , understanding that the brain can change and that they are resolutely a bad person because they are a young defenders institute.

Answer 57

Salekin et al. (2012) has done something nice with young offenders which has been about using cognitive behaviour training, understanding that the brain can change and that they are resolutely a bad person because they are a young defenders institute. Got them to do a lot of exercises about ‘your brain in basically a muscle, if you want to change the way your brain works, you have to exercise that, by making those new connections yourself, and keep exercising the brain in oder to be able to do it. Salekin found some really nice outcomes, including motivation to behave in a more pro social way. Salekin et al. (2012) 24 detained youth (mean = 14 years). Used: motivational techniques, cognitive behaviour training, and instruction on positive emotion, 12 didactic sessions, including numerous exercises. What’s the alternative? Work to strengths! Newly acquired behaviours are likely to become part of their behavioural repertoire when they are rewarded. Behaviours that are rewarded are more likely to be repeated.

Question 58

If punishment doesn’t work, then we work to strengths and reward behaviours which are more likely to be repeated.

Special considerations.

e.g., Lochman et al. 2008).

Answer 58

If punishment doesn’t work, then we work to strengths and reward behaviours which are more likely to be repeated. What we need to do, especially with children with deficient reward processing, we need to be very clear about what we are expecting and what we are rewarding by specifying the behaviour that is expected for the child to understand what behaviour is being praised. It can be very difficult for children with behavioural difficulties to get this. Its also really difficult (schools do this alot) is to make children what a long time to get a reward for good behaviour. Short intervals of rewards whenever possible, 3 times a day and always a chance to win back so the child is never pushed into a corner. The child needs a get out option.

Special considerations. In children with deficient reward processing, adults need to be extremely clear in specifying the behaviour that is expected for the child to understand what behaviour is being praised. To increase attention to rewards, shorter behavioural monitoring intervals should be used during intervention and more frequent and more salient rewards should be used as consequences for children accomplishing behavioural goals (e.g., Lochman et al. 2008).

Question 59

Summary.

Answer 59

CU traits can be considered a useful way of delineating conduct problems in children. There is genetic, brain-based and neuropsychological evidence for differences in those children with CU and those without. Cause for cautious optimism. Intervention strategies are currently being evaluated, but appear promising at reducing aggression, externalising problems and CU traits.