Lahey - PsycNET - American Psychological Association

Psychological Bulletin 2014, Vol. 140, No. 1, 64 – 68

© 2014 American Psychological Association 0033-2909/14/$12.00 DOI: 10.1037/a0033710

REPLY

The Road Forward for Research on Callous-Unemotional Traits: Reply to Lahey (2014) Paul J. Frick, James V. Ray, Laura C. Thornton, and Rachel E. Kahn

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University of New Orleans Lahey (2014) provides a thoughtful and scholarly discussion of our review of the research on the potential utility of callous-unemotional (CU) traits for designating a distinct subgroup of children and adolescents with severe conduct problems. In this reply, we attempt to clarify several issues raised in Lahey’s commentary. Specifically, by focusing largely on only 1 part of the research review (i.e., implications for evaluating the new specifier included for the diagnosis of conduct disorder in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders; American Psychiatric Association, 2013), the commentary underestimates the available empirical support for the utility of these traits for designating an important subgroup of children and adolescents with severe conduct problems. Furthermore, we highlight a number of studies that provide data inconsistent with the model proposed by Lahey in which CU traits are best considered as solely a marker of more severe conduct problems. Finally, we highlight limitations in estimating the stability of CU traits based solely on the number of individuals who continue to fall above and below a diagnostic cutoff at 2 points in time. Keywords: reply, conduct disorder, callous-unemotional traits, DSM–5

emotional deficits should be conceptualized as relating to the overall construct of CU traits, (b) how these emotional deficits should be assessed in measures of CU traits, and (c) the role of anxiety and fear (and negative emotionality in general) in the development of CU traits and CD. Besides the importance of each of these specific recommendations for guiding future research, they highlight what we believe may be one of the most important potential contributions for considering CU traits in relation to CD. Specifically, CD is defined as a behavioral disorder, in which the rights of others and major age appropriate norms are violated and it is diagnosed on the basis of the presence of aggression, destruction of property, deceitfulness and theft, and serious violations of rules. Moreover, as noted in our review (Frick et al., 2014), most past attempts to define meaningful subgroups of individuals with CD have focused on the type, severity, and onset of these behaviors. Research on CU traits could help focus attention on the emotional factors that are involved in the development of serious conduct problems, including those for individuals who meet the diagnostic criteria for CD. The importance given to emotional factors in Lahey’s (2014) research agenda is a very encouraging sign in this regard. Despite our many points of agreement with Lahey’s (2014) evaluation of past research and vision for advancing research on CU traits, we would like to clarify a few issues related to some of the interpretations that were made about the current state of research and several recommendations made for future studies.

We greatly appreciate the thoughtful and scholarly commentary provided by Lahey (2014) on our comprehensive review of research testing the potential usefulness of callous-unemotional (CU) traits for enhancing our understanding, diagnosis, and treatment of severe conduct problems in children and adolescents (Frick, Ray, Thornton, & Kahn, 2014). We agree with the vast majority of the points made in this commentary and, most important, we fully support the summary conclusion of Lahey: There is encouraging evidence regarding the role of CU in understanding the heterogeneity of CD [conduct disorder], but much remains to be learned. The publication of DSM–5 [Diagnostic and Statistical Manual of Mental Disorders—5th edition] should not be viewed only as the culmination of a long process of developing and studying the construct of CU. Rather, it is an important intermediate step that hopefully will motivate future studies of the roles of dispositional constructs in the etiology, mechanisms, prevention, and treatment of the heterogeneous diagnostic category of CD. (Lahey, 2014, p. 62)

Furthermore, Lahey (2014) made a number of recommendations for future research that could be critical for understanding the role of emotion in the development of CU traits and CD. These recommendations include the need to further investigate (a) how

Paul J. Frick, James V. Ray, Laura C. Thornton, and Rachel E. Kahn, Department of Psychology, University of New Orleans. Correspondence concerning this article should be addressed to Paul J. Frick, Department of Psychology, University of New Orleans, 2001 Geology and Psychology Building, New Orleans, LA 70148. E-mail: [email protected]

Being Too DSM-Centric The first issue relates to Lahey’s (2014) specific focus on the relevance of our review for the new specifier included in the 64


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DSM–5 (American Psychiatric Association, 2013) for the diagnosis of CD: namely, “with Limited Prosocial Emotions.” Specifically, we intended for Frick et al. (2014) to have a much broader focus than its implications for a single diagnosis from a single classification system. We focused on the implications of the available research on CU traits for understanding the heterogeneity in causes, severity, outcomes, and treatment response among children and adolescents with serious conduct problems, irrespective of whether they meet the specific criteria for CD. Clearly, this body of research has relevance for those diagnosed with CD, which is the primary diagnostic category used to classify children and adolescents with serious conduct problems in the DSM–5. As noted by Lahey (2014), the research that we reviewed provided much of the empirical basis for the decision to include the specifier in the DSM–5 and for how it was defined (http://www.dsm5.org/ Documents/Conduct%20Disorder%20Fact%20Sheet.pdf). Given this relevance to the changes in the diagnostic criteria for CD, we were careful to make explicit when the available research did and did not use the criteria for CD when investigating whether CU traits designate important subtypes of children and adolescents with serious conduct problems. Furthermore, we included in our review a focused discussion of the subset of studies particularly relevant for evaluating the specifier for CD. However, there are three important consequences of having a narrow focus on the small section of the review specific to the DSM–5 specifier. First, and most generally, it fosters a view that research on important psychopathological constructs should be solely guided by DSM–5 criteria. As noted by others, reliance on a single imperfect system with a specific framework that defines mental disorders solely on the basis of outward behavioral symptoms could greatly limit potential advances in causal research (Insel et al., 2010). Second, this narrow focus led to some overstatements of the limitations of the existing research. For example, Lahey (2014) highlighted a few studies that directly compared subgroups of children or adolescents who met criteria for CD but differed in the presence of the specifier, concluding that “it is essential to determine whether CU is related to important criterion variables over and above measures of the severity of CD” (p. 62). This evaluation did not consider the 30 studies that reported results indicating that psychopathic or CU traits were associated with antisocial outcomes even after controlling for conduct problem severity but that did not use strict DSM definitions of CD (Frick et al., 2014). Similarly, Lahey (2014) concluded that the results of the longitudinal study by McMahon and colleagues (McMahon, Witkiewitz, Kotler, & The Conduct Problems Prevention Research Group, 2010) made it “impossible to the evaluate the predictive validity of CU as a subtyping variable” (p. 60), but this conclusion was based on a very small, select set of analyses reported in this study— namely, the differences in predictive power for antisocial outcomes in those with CD alone and those with CD plus the CU specifier. This conclusion did not consider the more psychometrically sound main analyses demonstrating that CU traits assessed in seventh grade significantly predicted adult antisocial outcomes (e.g., adult arrests, adult antisocial personality symptoms) controlling for the symptoms/diagnosis of attention deficit hyperactivity disorder, oppositional defiant disorder, CD, and childhood onset of CD (McMahon et al., 2010).

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Third, the primary conclusions for future research focus on the need for additional studies using the DSM–5 definition of CD. We agree that this has direct relevance for future editions of the DSM and whether and how it operationalizes CU traits in its criteria for CD. However, we strongly caution against this as the sole focus of research because it would greatly limit our understanding of the development of CU traits and its potential role in designating a distinct subgroup of children with serious conduct problems, many of whom may not meet criteria for CD. For example, there is evidence that CU traits can be present in some samples in the absence of serious conduct problems (Kumsta, Sonuga-Barke, & Rutter, 2012). Further, CU traits predict future impairment (Moran, Ford, Butler, & Goodman, 2008) and are associated with distinct patterns of emotional functioning (Musser, GallowayLong, Frick, & Nigg, 2013) in children without CD (see also Rutter, 2012). Furthermore, a focus solely on children who already have CD could even limit advances in our understanding of how CD develops. For example, Viding, Blair, Moffitt, and Plomin (2005) studied a large (n ⫽ 7,374) population sample of 7-year-old twins and compared the genetic influences on conduct problems in children who scored above the 90th percentile on a measure of conduct problems but who differed on their level of CU traits. It is likely that this methodology, which did not use the diagnostic criteria for CD, captured more children who will later develop CD (i.e., those with age nonnormative levels of conduct problems) than studies limited to only those few young children who were already showing conduct problems severe enough to meet the diagnostic criteria for CD.

Do the Subgroups of Conduct Disorder Simply Reflect Differences in Severity? A critical issue clearly articulated in Lahey (2014) is the question of whether the presence of CU traits simply designates a more severe variant of CD that could be captured in a more parsimonious manner, such as by the number of conduct problems a child exhibits or by the presence of aggression. As succinctly stated in his conclusion, Lahey noted that “because CU is positively correlated with the number of CD symptoms (or the number of aggressive CD symptoms), it is essential to determine whether CU is related to important external criterion variables over and above measures of the severity of CD” (p. 62). We agree with the critical importance of this question. Yet results from existing research not supporting this severity model were not sufficiently considered in the Comment. As noted above, we reviewed 30 studies reporting that psychopathic or CU traits were associated with antisocial outcomes even after controlling for conduct problem severity (Frick et al., 2014). More important, there were a number of studies showing that conduct problems in the absence of elevated CU traits were associated with more severe risk factors or that conduct problems in the absence of elevated CU traits were associated with different external correlates compared with conduct problems displayed with elevated CU traits. Such findings would be hard to reconcile with a model proposing that the presence of CU traits is simply a marker of more severe conduct problems. We provide only a few examples here. One includes the studies reporting that conduct problems in the absence of elevated CU traits were more strongly associated with inconsistent and harsh


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parenting (e.g., Oxford, Cavell, & Hughes, 2003; Pasalich, Dadds, Hawes, & Brennan, 2012; Wootton, Frick, Shelton, & Silverthorn, 1997) and were more highly associated with anxiety (Frick, Lilienfeld, Ellis, Loney, & Silverthorn, 1999; Pardini, Stepp, Hipwell, Stouthamer-Loeber, & Loeber, 2012). In addition, a number of studies reported that children and adolescents high on CU traits were impaired in their responsiveness to cues of fear and sadness in others, whereas children or adolescents with severe conduct problems but normative levels of CU traits showed enhanced emotional responsiveness to distress cues in others (Kimonis, Frick, Fazekas, & Loney, 2006; Kimonis, Frick, Muñoz, & Aucoin, 2008; Loney, Frick, Clements, Ellis, & Kerlin, 2003). Finally, boys with conduct problems and elevated levels of CU traits demonstrated a different amygdala response following exposure to fearful faces and during a theory of mind task when compared with those normative on CU traits (Sebastian et al., 2012; Viding et al., 2012). Such differences in the type of amygdala responses (i.e., enhanced vs. reduced) would be difficult to explain solely by differences in the severity of conduct problems.

Issues in Estimating Stability Another issue raised by Lahey (2014) involved concerns about whether the “CU subtypes of CD are stable enough to be viewed as trait-like characteristics of subgroups of children with CD” (p. 61). This concern was largely based on the longitudinal study of Pardini et al. (2012), in which there were no significant differences in the rate of meeting the DSM–5 specifier 6 years later, for girls with CD with versus without the specifier at the initial assessment. We agree that determining the level of stability of CU traits across different age groups (Obradovic´ , Pardini, Long, & Loeber, 2007) and uncovering factors that may influence this stability (Frick, Kimonis, Dandreaux, & Farrell, 2003) are critical foci of research. However, using the number of individuals who meet the diagnostic cutoff at one point in time and who maintain this diagnosis at a second single point in time is not the best way to evaluate the stability of the construct or even the specifier itself. That is, evaluating the stability of a dichotomized variable at two points in time can lead to dramatic underestimates of the stability of a construct because it exaggerates small differences around the diagnostic cut point. Concretely, a person with two symptoms of the specifier who just crosses the diagnostic threshold at one point in time may vary around this threshold at later assessments because of either minor variation in symptom severity or measurement error associated with the method for assessing the construct. A good example of this problem can be found in studies estimating the stability of CD itself. That is, in a clinic-referred sample of boys, only half of the 65 who met criteria for CD in the first year of the study met criteria for CD 1 year later, but the vast majority (88%) met criteria at least once in the ensuing 3 years (Lahey et al., 1995). This issue is also illustrated in the Pardini et al. (2012) study of girls, which reported low stability of the dichotomous specifier. Specifically, when CU traits were used as a continuous variable in multiple regression analyses, CU traits at the initial assessment predicted level of CU traits 6 years later controlling for earlier CD symptoms (␤ ⫽ .28, p ⬍ .001), whereas CD symptoms did not predict CU traits 6 years later after controlling for initial levels of CU traits (␤ ⫽ ⫺.02, ns).

Thus, research should estimate the stability of CU traits using a number of different methods. Furthermore, a number of studies have provided some initial data on the stability of CU traits at different ages. Specifically, in early childhood (ages 2 to 8 years), three studies provided five stability coefficients for CU traits measured by the same informant and method over a period of 6 months to 2 years, with a mean stability estimate of .59 (range of .41 to .84; Hawes & Dadds, 2007; Waller et al., 2012; Willoughby, Waschbusch, Moore, & Propper, 2011). Moreover, five studies examined the stability of CU traits across childhood and adolescence and provided 86 stability coefficients over follow-up intervals ranging from 1 to 9 years, with a mean stability coefficient of .59 (range of .27 to .84; Barry, Barry, Deming, & Lochman, 2008; Muñoz & Frick, 2007; Obradovic´ et al., 2007; Pardini, Lochman, & Powell, 2007; van Baardewijk, Vermeiren, Stegge, & Doreleijers, 2011). Importantly, the Obradovic´ et al. (2007) study contributed 72 correlations to this summary with estimates given across nine separate time points from ages 8 to 16 years and using both teacher and parent reports. The stability of CU traits by parent report ranged from .77 across 1 year to .50 across 9 years and CU traits by teacher report ranged from .61 across 1 year to .27 across 9 years (all ps ⬍ .001). Finally, three studies estimated the stability of CU traits from childhood/adolescence to adulthood. Specifically, Forsman, Lichtenstein, Andershed, and Larsson (2008) reported that the stability of CU traits from ages 16 to 19 years was r ⫽ .43 and r ⫽ .54 (both p ⬍ .05) for boys and girls, respectively. In a somewhat older sample, Blonigen, Hicks, Kruger, Patrick, and Iacono (2006) reported a stability coefficient of r ⫽ .60 (p ⬍ .001) from ages 17 to 24. Finally, Burke, Loeber, and Lahey (2007) reported that both parent- and teacher–rated CU traits assessed at ages 7 to 12 in a sample of clinic-referred boys (n ⫽ 177) were significantly associated with clinician-rated CU traits at ages 18 and 19. In summary, such research provides initial data suggesting that the stability of CU traits is similar to what is found for other personality (Roberts & DelVecchio, 2000) and psychopathological (Verhulst & Van Der Ende, 1995) constructs assessed in children and adolescents.

Conclusions Once again, we appreciate Lahey’s (2014) evaluation of our review of the research on the potential utility of CU traits for designating a distinct subgroup of children and adolescents with severe conduct problems and we agree with most of his suggestions for future research, especially his call for more research investigating the emotional processes that could influence the development and outcome of children with serious conduct problems. We also appreciate the opportunity to clarify several issues raised in the Lahey Comment. Specifically, by focusing largely on the implications of this research for evaluating the new specifier included for the diagnosis of CD in the DSM–5, Lahey (2014) underestimated available evidence supporting the potential utility of these traits for designating an important subgroup of children and adolescents with severe conduct problems. Thus, we suggest that future research should not be limited to studies using DSM–5 criteria for either CD or the specifier “with Limited Prosocial Emotions.” Moreover, we highlight a number of studies that provide data inconsistent with a model proposed by Lahey (2014), in which CU traits are best considered as solely a marker of more

REPLY TO LAHEY (2014)

severe conduct problems. Finally, we highlight limitations in estimating the stability of CU traits based on the number of individuals who continue to fall above and below a diagnostic cutoff at two points in time.


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Received June 4, 2013 Accepted June 10, 2013 䡲