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Callous and Unemotional (CU) traits are distinguished by a persistent pattern of behavior that reflects a disregard for others, a lack of empathy and generally deficient affect. A CU specifier is being proposed for inclusion as a distinct subset of Conduct Disorder in the updated Diagnostic and Statistical Manual, (DSM-V). There appear to be strong genetic and neurobiological contributing factors to CU traits, while social and environmental factors may play a role in the expression of these traits as a conduct disorder.

Behavioral
Children with CU traits have distinct problems in emotional and behavioral regulation that distinguish them from other antisocial youth and show more similarity to characteristics found in adult psychopathy. Young adolescents with higher levels of CU traits were more likely to engage in direct and indirect forms of bullying. In addition to chronic delinquency, children and adolescents rated high on CU traits experience lower levels of fear and decreased concern about punishment, which in turn is a significant predictor of extreme violence in delinquent acts. In general, children or adolescents with CU traits exhibit more severe and instrumental displays of aggression than individuals with non CU conduct disorder.

Cognitive
Antisocial youth with CU traits tend to have a range of distinctive cognitive characteristics. They are often less sensitive to punishment cues, particularly when they are already keen for a reward ; ; and tend to expect more positive outcomes in aggressive situations with peers. Studies also indicate that antisocial youth with CU traits do not have verbal skill deficits—a common marker of youth with conduct disorder absent CU traits. In fact, CU traits tend to be positively related to intellectual skills in the verbal realm. However, CU-affected children tend to have weaker non-verbal abilities.

Diagnosis
Past research has attempted to subtype this subset of youth by distinguishing between those with childhood-onset versus adolescent-onset Conduct Disorder, Conduct Disorder co-morbid with ADHD, or by the severity and type of aggression displayed. The more recent advent of the Inventory of Callous-Unemotional Traits has allowed for CU traits to be reliably and accurately assessed in youth, confirming the presence of three independent factors in relation to high presence of CU traits: uncaring, callous, and unemotional. The ICU has proven to be equally reliable for male and female populations.

In terms of clinical utility, the severity of CD can be reliably predicted in children rated high on CU traits. Children are typically diagnosed with CU traits between third and seventh grade although they have been shown to remain fairly constant throughout adolescence.

Proposed Addition to DSM-V
The recommendation to add the “with significant callous-unemotional traits” specifier to the conduct disorder diagnosis in the DSM is hoped to further the understanding of the etiology and life-course of a specific group of antisocial youth, as well as further developmental models of antisocial behavior and psychopathic traits. Provision of the CU specifier for CD youth could have several implications by increasing diagnostic power and understanding life-course outcomes and treatment options.

It is proposed that for a child or adolescent to qualify for a diagnosis of callous-unemotional disorder, they must:

A)	Meet the full DSM-IV criteria for conduct disorder

B)	Exhibit 2 of the following symptoms for 12 months or longer in more than one relationship or setting.

•	Lack of remorse or guilt: Lack of guilt for any wrongdoings committed except in the face of punishment

•	Callous-lack of empathy: Blatant disregard about the feelings of others

•	Unconcerned about performance: Lack of concern about poor performance and work ethic in a school, work, or important environments

•	Shallow or deficient affect: Rarely or never expresses feelings or displays emotions to others, except in seemingly superficial ways, especially as a manipulation tactic (i.e. emotions inconsistent with actions; ability to turn “on” and “off” emotions).

Neural Mechanisms
Abnormally low cortisol levels may be a biological marker for individuals suffering from CU traits. Research has found that CU males had lower resting cortisol levels, and therefore lower hypothalamic-pituitary-adrenalHPA axis activity, compared to healthy individuals. The fearlessness theory of CU traits suggests that low amounts of cortisol lead to underarousal, causing impairments in fear processing, a trait seen in CU individuals. Hypoactivity in the HPA axis in combination with environmental stressors is thought to cause the development of antisocial behavior. However, recent studies have found that hypoactivity in the HPA in combination with CU traits seem to cause antisocial behavior even without external hardships.

FMRI research has demonstrated that decreased amygdala activation in response to fearful faces as well as distress based social cues is seen in children with CU traits. Further research has demonstrated decreased functional connectivity between the amygdala and regulatory regions. This includes decreased connectivity with the orbitofrontal cortex when making moral judgments, and decreased functional connectivity between the amygdala and ventromedial prefrontal cortex, with symptom severity negatively correlated with connection strength.

Genetics
Twin studies have found CU traits to be highly heritable, and not significantly related to environmental factors such as socioeconomic status, school quality, or parent quality. Two significant twin studies have suggested a significant genetic influence for CU, with an estimated average amount of variation (42.5%) in CU traits accounted for by genetic effects,. Notably, a substantial proportion of this genetic variation occurred independent of other dimensions of psychopathy. Children with conduct problems who also exhibit high levels of CU traits reflect a particularly high heritability rate of 0.81, as reflected in longitudinal research.

Exposure to Violence
Despite the strong genetic component to the presence of CU traits, environmental influences may play a role in the degree of severity of these traits. Children and adolescents exposed to high levels of community violence had greater deficits in emotional processing that CU individuals not exposed to such violence.

Combined Effects
Children who have low anxiety and parents who treat them with low warmth and involvement are more likely to develop CU traits. Aggressive youth, as well as those who have also been abused or exposed to violence in the community, are more likely to have CU traits, possibly due to a lack of response to distress cues.

Ethnicity
There may be ethnicity effects on the association between CU traits and emotional deficits, for not as strong of a connection was found between CU traits and psychopathy in African Americans as there was in Caucasians.

History
Due to the potential severity of antisocial and violent traits seen in adult psychopathy, significant research has focused on the importance of identifying the associated traits in childhood. In adult psychopathy, researchers have demonstrated that individuals with primarily affective and interpersonal deficits show a distinct etiology compared to individuals with antisocial, affective and interpersonal traits. Similarly, recent research has made it increasingly clear that different subtypes of aggressive and antisocial behaviors in youth may predict distinct problem-behaviors and risk factors in the future. There have been a number of attempts to officially designate psychopathic-like traits in antisocial youths based on the affective and interpersonal traits of psychopathy. The third edition of the Diagnostic and Statistical Manual of Mental Disorders divided Conduct Disorder into four subtypes: Unsocialized-Aggressive, Undersocialized-Nonaggressive, Socialized-Aggressive, and Socialized-Nonaggressive in an attempt to recognize the existence of psychopathic traits in children. The distinction between “socialized” and “unsocialized” children was the most pertinent in distinguishing between psychopathic-like youths. According to these definitions, “undersocialized” children exhibited characteristic behaviors of psychopathy, including: lack of empathy, lack of affection, and inappropriate social relationships (DSM III). This differed from “socialized” individuals, who were able to form healthy social attachments to others, and whose aggressive and antisocial acts typically derived from engagement in a deviant social group (e.g. youth gangs).

Following the publication of DSM-III, these distinctions prompted a great deal of promising research, but there were still issues with the terminology in diagnosing the core features of the undersocialized versus socialized subtype. The word “undersocialized” was used in order to avoid the negative connotations of “psychopathy,” but was commonly misinterpreted to mean that the child was not well socialized by parents or lacked a peer group ( . Also, the operational definition failed to include dimensions that could reliably predict the affective and interpersonal deficits in psychopathic-like youths . Due to these issues, the American Psychiatric Association removed the undersocialized and socialized distinctions from the Conduct Disorder description in the DSM after the third edition. The only subtypes that have been included in the manual since then relate to the time of onset: childhood-onset (before age 10), adolescent-onset (absence of antisocial traits before age 10), and unspecified-onset ;, DSM IV).

Prognosis
Childhood-onset CU shows a more aggressive and stable pattern of antisocial behavior with higher rates of CU traits, as well as more severe temperamental and neuropsychological risk factors relative to their adolescent-onset counterparts. Children with combined CD and ADHD are more likely to show features associated with psycopathy, but only in those who have high rates of CU traits. In support of the idea of lifetime persistence of CU traits, childhood-onset delinquency has been more strongly associated with psychopathic traits than adolescent-onset delinquency. A longitudinal twin study of children with CD showed that high or increasing levels of CU traits comorbid with CD presented with the most negative outcomes after twelve years in relationships with peers and family, as well as emotional and behavioral problems, as compared to those with low CU traits or CD alone. In addition, adolescents with CU traits have shown higher likelihood to commit a violent crime within a two year period of their release from a correctional facility than those without CU traits. Crimes committed by individuals with CU traits are more likely to be premeditated, and antisocial youth with CU traits tend to show less response to treatment.

Support and Treatment
Though CU traits are relatively stable, they can decrease over time through effective treatment. Early intervention is thought to be more effective because CU traits are thought to be more malleable early in life.

Parenting Techniques
Children who are high in callous-unemotional traits are inherently hard to socialize, no matter how good the parenting is. However, quality parenting can decrease the manifestation of CU traits (Hawes & Dadds, 2005). Children with high CU traits are less responsive to time-out and other punishing techniques than are healthy children as time-out does not seem to bother them, so their behavior does not improve. Reward-based disciplining techniques, such as praise and reinforcement, tend to have a greater effect than punishing techniques on children with high CU traits. Furthermore, strategies that focus on positive parental intervention, including using less physical punishment and more parental warmth and involvement seem most effective in managing CU traits.

Medication and Therapy
Behavioral therapy alone does not seem to reduce CU traits over time. However, people with CU traits respond just as well as those without CU traits if medication, such as methylphenidate, is combined with behavioral therapy.

Multi-Component Treatment
Taking an approach involving multiple forms of intervention is helpful in improving CU traits and maintaining those improvements over at least a three-year period of time. Many different types of intervention exist and can be combined together to have a lasting effect on children high in CU traits. For a child with CU traits, cognitive behavioral therapy can be used for skills training, and medication is especially helpful for those with both CU traits and ADHD. Parent training can help parents learn how to best discipline their CU children (Hawes et al, 2007). Group forms of intervention, including parent-child/family therapy and school programming/teacher consultation, can also be successful. To improve social skills and the social interactions of those with CU, possible treatments include peer relations/community activities development and crisis management on a case-by-case basis.

Gender Differences
It has been speculated that an intervention based on a gender-sensitive cognitive-behavioral model may be beneficial when treating females with CU traits due to female peer group dynamics differing significantly from that of the male peer group.