Early Identification and

Tre a t m e n t o f A n t i s o c i a l
Behavior
a,b,
Paul J. Frick, PhD *

KEYWORDS
 Antisocial behavior  Early identification  Treatment  Callous-unemotional traits
 Emotional regulation  Diagnosis

KEY POINTS
 Individuals most likely to show severe and persistent antisocial behavior often begin
showing severe conduct problems early in childhood.
 Callous-unemotional (CU) traits are characterized by a lack of guilt, a lack of empathy, a
restricted display of affect, and a failure to put forth the effort to succeed in important
activities.
 The level of CU traits seems to differentiate subgroups of children and adolescents with
serious conduct problems who differ in the severity and persistence of their antisocial
behavior.
 The level of CU traits also seems to differentiate subgroups of children and adolescents
with serious conduct who have different causes to their behavior problems.
 Treatment is enhanced when it is tailored to the unique characteristics of antisocial youth
with and without elevated CU traits.

INTRODUCTION

Antisocial behavior in children and adolescents is generally defined by behavior that

violates the rights of others, such as aggression, destruction of property, and theft;
or behavior that violates major age-appropriate societal norms or rules, such as
truancy and running away from home.1 Serious and persistent patterns of antisocial
behavior in children and adolescents form the diagnostic criteria for conduct disorder
(CD),1 and CD is a critical mental health concern for several reasons:
 It is highly prevalent with a worldwide prevalence among children and adoles-
cents ages 6 to 18 estimated at 3.2%.2

Disclosure Statement: The author has nothing to disclose.

a
Department of Psychology, Louisiana State University, Baton Rouge, LA 70802, USA; b Learning
Sciences Institute of Australia, Australian Catholic University, Melbourne, VIC, Australia
* Department of Psychology, Louisiana State University, Baton Rouge, LA 70802.
E-mail address: pfrick@lsu.edu

Pediatr Clin N Am 63 (2016) 861–871

http://dx.doi.org/10.1016/j.pcl.2016.06.008 pediatric.theclinics.com
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862 Frick

 It operates at a high cost to society because of the reduced quality of life for the
victims of the antisocial acts and the financial costs to the legal system that must
respond to the acts that violate laws.3
 It predicts a host of problems in adjustment for the person with the disorder
throughout their lifespan, including mental health problems (eg, substance
abuse), legal problems (eg, risk for arrest), educational problems (eg, school
dropout), social problems (eg, poor marital adjustment), occupational problems
(eg, poor job performance), and physical health problems (eg, poor respiratory
function).4
Given the prevalence, cost, and impairment associated with CD, it is not surprising
that a substantial amount of research has been conducted to understand the causes
of this disorder and to use this knowledge to develop effective methods to prevent or
treat it. One of the most consistent findings from this work is that interventions that
seek to target a reduction in antisocial behavior are least costly and most effective
if they are implemented early in childhood.5 As a result, a substantial amount of
research on CD has focused on identifying early markers that predict either who will
develop the disorder or who is at risk for showing the most severe and persistent forms
of antisocial behavior once it develops.

BEHAVIORAL APPROACHES TO EARLY IDENTIFICATION

Types of Behavior Associated with Poor Outcomes
Early research attempting to identify early indicators of risk for persistent antisocial
behavior focused on the frequency and severity of the behavior displayed, with
severity being defined as the number and variety of different behaviors displayed by
the child and the number of settings in which the child displays the behaviors.6 For
example, Robins reported on a classic longitudinal study of 314 children referred to
a child mental health clinic for CD symptoms and reported that the risk for showing
an antisocial disorder as an adult was a linear function of the number of symptoms
exhibited in childhood.7 Specifically, 15% of children with 3 to 5 symptoms in child-
hood were diagnosed with an antisocial disorder as an adult, in comparison to 25%
of children with 6 or 7 symptoms, 29% of children with 8 or 9 symptoms, and 43%
of children with greater than 10 symptoms.
Another early marker of severity for children and adolescents with CD has been the
presence of aggression. That is, when antisocial behavior is separated into those be-
haviors that can be considered aggressive (eg, bullies others, initiates physical fights)
and those that are nonaggressive (eg, vandalism, lies, truant), the aggressive behav-
iors seem to be more stable and stronger predictors of problems continuing into adult-
hood.8 In addition to simply documenting the presence of aggression, there has been
research suggesting that the form that the aggression takes could be important. For
example, research has distinguished between reactive aggression, which occurs as
an angry response to provocation or threat, and proactive aggression, which is typi-
cally unprovoked and often used for instrumental gain or dominance over others.9
Research suggests that some children with severe conduct problems only show reac-
tive forms of aggression, whereas others show a combination of both reactive and
proactive forms of aggression.10 Children showing combined forms of aggression
often have more problems across development.9
Thus, research suggests that the number, severity, and degree of harm that a child’s
antisocial behavior causes to others are important factors to consider as markers of
risk for poor outcome. To reflect this, the diagnostic criteria for CD in the most recent
editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM)1,11 have
 Early Identification of Antisocial Behavior 863

required that the person must show at least 3 different antisocial behaviors over the
past 12 months to be diagnosed with CD, and then the severity is coded as:
 Mild: with few symptoms beyond the diagnostic threshold and behavior that
causes relative minor harm to others (eg, lying, truancy);
 Moderate: the number of symptoms and amount of harm to others is intermedi-
ate to those specified as “mild” or “severe”;
 Severe: many symptoms beyond the diagnostic threshold that cause consider-
able harm to others (eg, rape, use of a weapon).

Childhood Onset Conduct Disorder

Another important variation in how antisocial behavior is expressed in children is the
age at which the serious antisocial behavior is first displayed. Persons who begin
showing behavior problems before adolescence are much more likely to continue to
show problems into adulthood compared with those whose problems onset during
adolescence. For example, in a birth cohort from New Zealand that was followed
into adulthood, the rate of official convictions for violent acts in adulthood (before
age 32) was as follows:
 32.7% for males who began showing serious conduct problems before
adolescence
 10.2% for males who began showing serious conduct problems in adolescence
 .4% for males who did not show serious conduct problems in either childhood or
adolescence.4
Even before adolescence, there is some indication that the younger the child begins
to show serious conduct problems, the more severe and persistent his or her antiso-
cial behavior is likely to be.12 Importantly, the age of onset of antisocial behavior may
subsume some of the other behavioral patterns that predict poor outcomes. That is,
age of onset is negatively associated with number of conduct problems and with
the level of aggression displayed by the child.12,13
As a result of this research, the most recent editions of the DSM have also included
criteria to distinguish early and late onset patterns of CD:
 Childhood-onset type: Individuals show at least one symptom characteristic of
CD before age 10 years.
 Adolescent-onset type: Individuals show no symptom characteristic of CD
before age 10 years.1
The different outcomes for these 2 subgroups of antisocial individuals may be due to
differences in the causal processes that lead to the different trajectories.13,14 Specif-
ically, the childhood-onset pattern seems to be more strongly related to neuropsycho-
logical (eg, deficits in executive functioning) and cognitive (eg, low intelligence)
deficits. Also, children who show the childhood-onset pattern seem to show more
temperamental and personality risk factors, such as impulsivity, attention deficits,
and problems in emotional regulation. As a result, this group often displays
attention-deficit hyperactivity disorder (ADHD), and it is possible that the presence
of ADHD contributes to their poor outcomes.15 Importantly for early identification,
the impulsivity and hyperactivity symptoms of ADHD often emerge before the child’s
conduct problems and can be the first indicator that the child is having problems regu-
lating their behavior and emotions.15
In contrast to this early-onset trajectory, persons whose antisocial behavior onsets
in adolescence typically do not show the same number and severity of dispositional
864 Frick

risk factors, like ADHD.13,14 However, they are often described as showing higher
levels of rebelliousness and being more rejecting of conventional values and status hi-
erarchies.16 As a result, youths in the adolescent-onset pathway are often considered
as showing an exaggeration of the normative process of adolescent rebellion in which
the adolescent engages in antisocial and delinquent behaviors as a misguided attempt
to obtain a subjective sense of maturity and adult status in a way that is maladaptive
(eg, breaking societal norms) but encouraged by an antisocial peer group.4

CALLOUS-UNEMOTIONAL TRAITS AND DEVELOPMENTAL PATHWAYS TO ANTISOCIAL

BEHAVIOR

All of these approaches to identifying children who are at most risk for showing persis-
tent antisocial behavior have focused on some aspect of how the antisocial behavior is
expressed (ie, number, type, or onset of the behavior). However, there is another
approach that focuses instead on the person’s affective and interpersonal style,
similar to definitions of psychopathy in adults.17 This style has been labeled as
“callous-unemotional (CU) traits” in research18 and as “limited prosocial emotions”
in diagnostic criteria for CD.1 Specifically, the 5th edition of the DSM includes a spec-
ifier (ie, “With Limited Prosocial Emotions”) that can be applied to persons who meet
criteria for CD but who show at least 2 of the following symptoms over an extended
period of time (ie, at least 12 months) and in multiple relationships and settings:
 Lack for remorse or guilt
 Callous-lack of empathy
 Unconcerned about performance in important activities
 Shallow or deficient affect.
These specific indicators and the diagnostic threshold of 2 symptoms were chosen
based on extensive secondary data analyses across large samples of youth in
different countries.19 Importantly, although only a minority (25% 30%) of children
with CD meets the criteria for this specifier, this group seems to differ from other anti-
social youth in many important ways.18

Differences Between Conduct Disorder with and Without Elevated Callous-

UnemotionalTraits
In terms of clinical importance, antisocial youth with CU traits (relative to other antiso-
cial youth) show the following:
 A more stable pattern of antisocial behavior that predicts a greater likelihood of
the antisocial behavior continuing into adulthood20,21
 More severe aggression that results in greater harm to others22,23
 Aggression that is more likely to be premeditated and instrumental (ie, for per-
sonal gain and dominance)22–24
 Poorer response to many of the typical health interventions used to treat CD.25,26
Thus, the presence of elevated CU traits identifies a group of antisocial youth who
are important for early intervention and treatment.
In addition, there is evidence that these traits also classify a group of youth with CD
who show very different genetic, cognitive, emotional, and social characteristics from
other antisocial youth.18 Specifically, antisocial youth with elevated CU traits (relative
to other antisocial children and adolescents):
 Show stronger genetic influences on their conduct problem behavior27
 Show an insensitivity to punishment cues under many conditions28
 Early Identification of Antisocial Behavior 865

 View aggression as a more acceptable means for obtaining goals and place
greater importance on dominance and revenge in social conflicts29
 Display reduced emotional responses to cues of distress in others30,31
 Show impairments in their selective attention to caregivers face in the first year of
life, make less eye contact with caregivers in childhood, and attend less to the
eye region in others later in life32–34
 Show conduct problems that are less related to hostile and coercive parenting
but are more strongly related to warm parenting35
 Are more likely to associate with deviant peers, are more likely to commit crimes with
peers, and are more influential in encouraging antisocial behavior in their peers.36,37
This extensive list of differences between antisocial youth with and without elevated
CU traits has led to several theories proposing different causes to the antisocial
behavior in the 2 groups. For example, children with serious conduct problems and
elevated CU traits have a temperament that could make them more difficult to socialize
(eg, less sensitive punishment) and miss early signs of distress in others (eg, reduced
emotional responses to others’ distress).38 These processes can interfere with the
normal development of key aspects of conscience (ie, empathy and guilt) and place
the child at risk for a particularly severe and aggressive pattern of antisocial behavior.
In contrast, children with childhood-onset antisocial behavior with normative levels
 Are highly reactive to emotional cues in others
 Are highly distressed by the effects of their behavior on others
 Display higher levels of emotional reactivity to provocation from others.
They show conduct problems that are
 Less strongly influenced by genetic factors
 More strongly associated with hostile/coercive parenting.14,18
Based on these findings, it appears that children in this group show a temperament
characterized by strong emotional reactivity combined with inadequate socializing ex-
periences that lead to failure in the development of the skills needed to adequately
regulate their emotional reactivity.39,40 The resulting problems in emotional regulation
can result in the child committing impulsive and unplanned aggressive and antisocial
acts, for which he or she may feel remorseful afterward, but for which he or she may
still have difficulty controlling in the future.

Implications for Research

From this brief review of research, it is clear that the distinction between antisocial youth
with and without elevated CU traits may encompass several of the previous attempts to
define important subgroups of children at risk for particularly severe and stable patterns
of antisocial behavior. Specifically, children with elevated CU traits and conduct prob-
lems tend to show a greater number of conduct problems, more aggressive behavior,
and more instrumental aggression.18 Furthermore, CU traits seem to designate a sub-
group of children within those with both ADHD and early conduct problems who show
distinct emotional and cognitive characteristics41 and who are at particularly high risk
for later antisocial behavior.21 With respect to the latter, McMahon and colleagues21 re-
ported that CU traits assessed in seventh grade significantly predicted adult antisocial
outcomes (eg, adult arrests, adult antisocial personality symptoms) even after controlling
for ADHD, oppositional defiant disorder, CD, and childhood-onset of CD.
The presence of elevated CU traits seems particularly important for guiding
research investigating the causes of antisocial behavior because they differentiate
866 Frick

groups with very different emotional and cognitive characteristics. To illustrate this,
Viding and colleagues31 reported that amygdala responses to fearful faces (relative
to calm faces) were stronger in boys (ages 10–16) with conduct problems without
elevated CU traits but were weaker in boys with conduct problems who were elevated
on CU traits compared with controls. Thus, ignoring the differences among the 2
groups high on conduct problems would have hidden the differences with controls
and led to erroneous conclusions on the potential importance of emotional responding
for understanding the development of conduct problems.
Another way that research on CU traits could be critical for causal theories of anti-
social behavior is that it promotes an integration of research on processes in typically
developing children with research on how these developmental processes can go
awry and lead to problem behavior.38 As noted above, many theories to explain the
differences between antisocial youth with and without elevated CU traits include pro-
cesses that have long been the focus of developmental research, such as how chil-
dren develop guilt, empathy, and other prosocial emotions and how children
develop the skills necessary to regulate their emotions.40 Thus, causal theories for
antisocial behavior can be advanced by integrating it with the vast research on con-
science development and the development of emotional regulation in non-antisocial
children.
Furthermore, this approach to research on antisocial behavior in children and ado-
lescents would be consistent with the research domain criteria (R-DoC) framework
that is being advanced by the National Institute of Mental Health. Specifically, the
R-DoC initiative was implemented to overcome some of the limitations in behaviorally
based approaches to classifying mental health disorders, such as the great heteroge-
neity in the neurocognitive mechanisms that can lead to a single behavioral diagnosis
like CD.42 As noted above, the use of CU traits seems to reduce this heterogeneity by
designating groups with similar behavioral manifestations (ie, CD) but with unique pro-
files of neurocognitive processes.39 Furthermore, these neurocognitive profiles can be
explained using the R-DoC domains, with the group without elevated CU traits
showing problems in the regulation of the negative emotional valence system respon-
sible for responses to aversive situations and contexts (eg, anxiety, frustration, and
loss) and the group with elevated CU traits showing problems primarily in the systems
for social processing that mediate responses to interpersonal settings, especially
related to affiliation and attachment.42 Thus, advances in knowledge of the RDoC do-
mains could be critical for guiding research on how these domains may be related to
the development of antisocial behavior.

Implications for Prevention and Treatment

The research on CU traits and the different developmental pathways to antisocial
behavior could also have many important implications for preventing and treating
CD. Existing research on effective treatments for antisocial behavior in children and
adolescents highlights the need to
 Intervene as early in development as possible
 Intervene with comprehensive treatments that target many dispositional and
contextual risk factors that can lead to or maintain the child’s antisocial behavior
 Tailor interventions to the unique needs of children and adolescents with serious
antisocial behavior, because the most important targets of intervention may vary
across antisocial individuals.43
Research on the differences between antisocial children and adolescents with and
without elevated CU traits can advance each of these goals.
 Early Identification of Antisocial Behavior 867

For example, as noted above, the most effective treatments for antisocial behavior
intervene early in development when the child’s conduct problems are less severe.43
The research on the different developmental mechanisms leading to CD could allow
interventions to target children who show temperamental vulnerabilities (eg, children
who miss early cues to others’ distress or who have problems regulating their emo-
tions) even before the serious conduct problems develop.44,45 Furthermore, parenting
interventions could be modified to meet the unique needs of these children with very
different temperaments.46
This ability to tailor treatments to the needs of the different youth with CD could
be the most important benefit of recognizing the various developmental pathways to
antisocial behavior. That is, the different characteristics associated with antisocial
behavior in those with and without elevated CU traits could help in determining
the most effective combination of services for an individual child or adolescent.
As noted previously, children and adolescents who show significant levels of
CU traits present quite a treatment challenge.18 However, despite their poor
response to many traditional treatments, their antisocial behavior can be reduced
when intensive treatments are tailored to their unique cognitive and emotional
characteristics.
For example, Hawes and Dadds26 reported that clinic-referred boys (ages 4–9)
with conduct problems and elevated CU traits showed reductions in their conduct
problems during the phase of a parenting intervention that focused on use of positive
reinforcement to encourage prosocial behavior. This outcome would be consistent
with the reward-oriented response style that appears to be characteristic of children
with CU traits. Similarly, Caldwell and colleagues47 demonstrated that adolescent of-
fenders with CU traits improved (ie, showed significant reductions in reoffending)
when treated using an intensive treatment program that used reward-oriented ap-
proaches, targeted the self-interests of the adolescent, and taught empathy skills.
Finally, White and colleagues48 tested the effectiveness of an intervention for adoles-
cents in the juvenile justice system that focused on engaging the child and family in
treatment and providing motivations for change that are individualized for each family
and child. Results indicated that CU traits were associated with improvements in
behavior over the course of treatment and with decreases in risk for reoffending at
6- and 12-month follow-ups. Thus, certain treatments can reduce the level and
severity of the antisocial behavior of youths with CU traits, if they are tailored to the
unique characteristics of this group.

SUMMARY

In summary, severe and persistent antisocial behavior is a serious and costly mental
health problem. Persistently antisocial individuals often start showing conduct prob-
lems early in development, and interventions that seek to treat these problems before
they worsen are the most effective and least costly. Thus, early intervention for serious
conduct problems is a critical goal for reducing the burden of antisocial behavior on
individuals and society. Furthermore, research has suggested that there are likely
several important causal pathways that lead to severe and persistent antisocial
behavior. One pathway involves a failure to develop appropriate levels of empathy,
guilt, and other aspects of conscience that leads to severe aggression that is planned
and instrumental in nature. Another pathway involves a failure to develop adequate
emotional regulation that leads to impulsive aggressive acts or other antisocial behav-
iors during periods of intense emotional arousal that interfere with the child’s ability to
adequately consider the consequences of his or her behavior. These developmental
868 Frick

pathways respond differently to treatment, and the most effective treatments are
tailored to the unique characteristics of individuals in the various groups.
This framework for understanding serious conduct problems in youths is important
for guiding research by illustrating the need to use designs and statistical procedures
that can capture the different associations with important causal variables across the
different pathways. Furthermore, the unique pattern of neurocognitive processes un-
derlying these different pathways fits well with the RDoC framework. As suggested by
this framework, prospective studies in which children are grouped according to the
different patterns of emotional, cognitive, and biological variables and then are fol-
lowed to track the onset of conduct problems could be critical for advancing causal
theory. Within such a research design, testing potential contextual factors that could
moderate the risk for antisocial behavior in youth with certain types of neurocognitive
risk could be critical for advancing interventions. For example, research suggests that
warm and responsive parenting may reduce the level of CU traits in children who are
temperamentally vulnerable to missing signs of distress in others.49 Such findings can
be used to enhance existing treatments and lead to better outcomes for children and
adolescents who heretofore have been resistant to typical mental health treatments.
Finally, now that these pathways have been integrated into diagnostic criteria, it is
likely that these distinctions among subgroups of youth with CD will be made more
commonly in clinical settings, and research is needed to develop and test valid and
cost-efficient means for making these distinctions.50

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