Can Callousness and Unemotionality in Children Be Treated?

By Deepak Seshadri, M.S., and Camilo Ortiz, Ph.D.

Hyperactive, non-compliant, disruptive, defiant, and aggressive child behaviors, or what psychologists call “externalizing behaviors,” are the most common reason parents seek out mental health help for their children. While it is entirely normal (and even healthy) for children to misbehave occasionally, these behaviors become problematic when sustained over long periods or when they worsen.

One such clinical presentation of these behaviors is called conduct disorder, which is characterized as a persistent pattern of behavior that violates the basic rights of others and violates age-appropriate social norms. Common examples of behaviors seen in children with conduct disorder can include aggression toward people or animals, destruction of property, deceitfulness or theft, and serious rule violations.

Callous-unemotional traits

Not all children with conduct disorder present the same way. The Diagnostic and Statistical Manual-5 offers a specifier, or subset of children with conduct disorder, who also show “limited prosocial emotions.” This term refers to children who present with a lack of remorse, lack of empathy (callousness), lack of concern about education or occupational performance, and shallow emotions. This constellation of behaviors is also called callous-unemotional traits.

Children with these traits are rare—perhaps 1-3 percent of all children. But treating them is important. Untreated, these children are at increased risk for a lifetime of antisocial behavior. In the past, these children have been considered very difficult to treat. But perhaps the real problem is that they have too rarely been treated by specialists who understand their unique needs and challenges and are trained to use approaches that work.

Behavioral parent training (BPT)

Behavioral parent training, or BPT, is a form of behavioral therapy that seeks to equip parents with behavior management skills that reduce problematic child behaviors. Common interventions typically found in parent training programs include psychoeducation, incentive-based reinforcement systems, and instruction in effective punishment, like time out and natural consequences, as compared to the ineffective punishments parents sometimes use, like spanking.

The therapist trained in BPT will work with the child’s parents to teach them how to implement these skills at home effectively. There are several parent training programs, as not one size fits all. BPT programs can be brief, long-term, administered to an individual family, administered in a group setting involving the child, or done without a therapist ever meeting the child. Regardless of the format, BPT is generally an effective treatment for children with disruptive and externalizing behaviors, including those with conduct disorder, and usually improves interactions between parents and their children.

But there are exceptions. Despite BPT’s overall success, it doesn’t seem to work as well for children who have conduct disorder and callous-unemotional traits. The main reason BPT is less effective with for these kids is that they appear to be, on average, “punishment insensitive,” which just means that they don’t care as much as other kids when they get in trouble. Most children have a strong emotional response when a parent is upset with them, and this feeling is uncomfortable. Kids with callous-unemotional traits don’t feel that discomfort as much, which weakens the effect of punishment for them.

Modifying BPT for kids with callous-unemotional traits

There have been efforts to develop modified interventions for children who present with callous-unemotional traits by focusing on the qualities that make them different. Effective treatments capitalize on three notable features of kids with callous-unemotional traits:

First, these kids have been shown to respond positively to parenting practices that emphasize warmth, sensitivity, and responsiveness.

Second, while children with callous-unemotional traits are less sensitive to punishment cues, they are sensitive to rewards.

Third, children with callous-unemotional traits have a difficult time with emotional processing, particularly when it comes to recognizing distress in others, which can interfere with effective treatment.

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Parent-child interaction therapy (PCIT)

The parent training protocol that has shown the most promise in addressing concerns specific to these features of callous-unemotional traits is parent-child interaction therapy (PCIT). This program targets the development of the parent-child relationship by focusing on teaching positive parenting strategies. Standard PCIT focuses on some features specific to callous-unemotional traits, but an even more targeted adaptation of this treatment was developed solely with CU-trait children in mind.

This intervention is known as PCIT-CU and has several key distinctions from standard PCIT that make it a better fit for a child with callous-unemotional traits. It emphasizes creating a warm and emotionally responsive parent-child dynamic, supplements punishment-based strategies with reward-based systems and provides an adjunctive, or “add-on,” treatment module called CARES that targets emotional skills.

CARES (or Coaching and Rewarding Emotional Skills) is a short-term treatment designed to improve emotion recognition and empathetic responding in children with CU traits who are relatively young (age 3 ½ – 8) and whose conduct problems are not yet clinically significant. The CARES module achieves this by setting key treatment objectives. These include increasing kids’ attention to others’ distress-related facial cues like fear and sadness, teaching emotional labeling and prosocial and empathetic behavior, and emphasizing cognitive behavioral strategies to reduce aggressive behavior.

Although this approach is new and only a few studies have been published so far, PCIT-CU+CARES has preliminarily shown effectiveness in treating children with callous-unemotional traits. Children treated using this approach show decreases in conduct problems and callous-unemotional traits and increases in empathy have been reported. Although further research will be needed to establish PCIT-CU+CARES as a gold-standard intervention, we are on the right track. The hope for consistent and reliable treatment for this population is on the horizon. Once that stage is reached, the challenging and essential work of training therapists to use interventions targeted at callous-unemotional can begin.

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