PCIT for Children with Callous-Unemotional Traits

  • Georgette E. Fleming
  • Eva R. KimonisEmail author


The risk factors for childhood conduct problems vary considerably across individuals, and effective intervention requires individualizing treatment to the unique needs of children on etiologically distinct developmental pathways. The importance of this causal heterogeneity is recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, which includes for the first time a specifier for the diagnosis of callous-unemotional (CU)-type conduct disorder (i.e., CD with limited prosocial emotions). This change was informed by decades of research supporting that CU traits designate a distinct subgroup of children with early starting, severe, and aggressive conduct problems that are not only associated with significantly increased risk of negative outcomes as adolescents and adults but are also less responsive to traditional interventions. This attenuated treatment response has been attributed to the failure of traditional interventions to adequately target the distinct risk factors involved in the development of CU-type conduct problems. Accordingly, an adaptation of parent–child interaction therapy (PCIT) was developed that addresses these unique risk factors. PCIT-CU, as it is known, differs from standard PCIT in three key ways: it (a) trains parents to engage in warm, emotionally responsive parenting to improve conscience development among temperamentally fearless children, (b) systematically supplements punishment-based parenting strategies with reward-based techniques, and (c) delivers emotional skill-building to target the distinct core emotional deficits of these children. Given there are currently few guidelines regarding best practice for the 20–50% of children with conduct problems that show elevated CU traits, this line of research is critical to improving their outcomes.


Conduct problems Disruptive behavior CU traits Psychopathic traits Empathy PCIT Parent training Early intervention 


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.CrossRefGoogle Scholar
  2. Auty, K. M., Farrington, D. P., & Coid, J. W. (2015). Intergenerational transmission of psychopathy and mediation via psychosocial risk factors. The British Journal of Psychiatry, 206(1), 26–31.CrossRefGoogle Scholar
  3. Bagner, D. M., Rodríguez, G. M., Blake, C. A., & Rosa-Olivares, J. (2013). Home-based preventive parenting intervention for at-risk infants and their families: An open trial. Cognitive and Behavioral Practice, 20(3), 334–348.CrossRefGoogle Scholar
  4. Barker, E. D., Oliver, B. R., Viding, E., Salekin, R. T., & Maughan, B. (2011). The impact of prenatal maternal risk, fearless temperament and early parenting on adolescent callous-unemotional traits: A 14-year longitudinal investigation. Journal of Child Psychology and Psychiatry, 52(8), 878–888.CrossRefGoogle Scholar
  5. Baron-Cohen, S., Golan, O., Wheelwright, S., & Hill, J. J. (2004). Mind reading: The interactive guide to emotions. London, England: Jessica Kingsley.Google Scholar
  6. Bedford, R., Wagner, N. J., Rehder, P. D., Propper, C., Willoughby, M. T., & Mills-Koonce, R. W. (2017). The role of infants’ mother-directed gaze, maternal sensitivity, and emotion recognition in childhood callous unemotional behaviours. European Child & Adolescent Psychiatry, 26(8), 947–956.CrossRefGoogle Scholar
  7. Blair, R. J. R. (2008). Fine cuts of empathy and the amygdala: Dissociable deficits in psychopathy and autism. The Quarterly Journal of Experimental Psychology, 61, 157–170.CrossRefGoogle Scholar
  8. Blair, R. J. R., Colledge, E., Murray, L., & Mitchell, D. (2001). A selective impairment in the processing of sad and fearful expressions in children with psychopathic tendencies. Journal of Abnormal Child Psychology, 29(6), 491–498.CrossRefGoogle Scholar
  9. Blair, R. J. R., Peschardt, K. S., Budhani, S., Mitchell, D., & Pine, D. (2006). The development of psychopathy. Journal of Child Psychology and Psychiatry, 47, 262–276.CrossRefGoogle Scholar
  10. Boggs, S. R., Eyberg, S. M., Edwards, D. L., Rayfield, A., Jacobs, J., Bagner, D., & Hood, K. K. (2005). Outcomes of parent-child interaction therapy: A comparison of treatment completers and study dropouts one to three years later. Child & Family Behavior Therapy, 26(4), 1–22.CrossRefGoogle Scholar
  11. Brestan, E. V., Jacobs, J. R., Rayfield, A. D., & Eyberg, S. M. (2000). A consumer satisfaction measure for parent-child treatments and its relation to measures of child behavior change. Behavior Therapy, 30(1), 17–30.CrossRefGoogle Scholar
  12. Dadds, M. R., & Salmon, K. (2003). Punishment insensitivity and parenting: Temperament and learning as interacting risks for antisocial behavior. Clinical Child and Family Psychology Review, 6(2), 69–86.CrossRefGoogle Scholar
  13. Dadds, M. R., Perry, Y., Hawes, D. J., Merz, S., Riddell, A. C., Haines, D. J., ... & Abeygunawardane, A. I. (2006). Attention to the eyes and fear-recognition deficits in child psychopathy. The British Journal of Psychiatry, 189(3), 280–281.CrossRefGoogle Scholar
  14. Dadds, M. R., Cauchi, A. J., Wimalaweera, S., Hawes, D. J., & Brennan, J. (2012). Outcomes, moderators, and mediators of empathic-emotion recognition training for complex conduct problems in childhood. Psychiatry Research, 199(3), 201–207.CrossRefGoogle Scholar
  15. Danko, C. M., Garbacz, L. L., & Budd, K. S. (2016). Outcomes of Parent–Child Interaction Therapy in an urban community clinic: A comparison of treatment completers and dropouts. Children and Youth Services Review, 60, 42–51.CrossRefGoogle Scholar
  16. de Wied, M., van Boxtel, A., Matthys, W., & Meeus, W. (2012). Verbal, facial and autonomic responses to empathy-eliciting film clips by disruptive male adolescents with high versus low callous-unemotional traits. Journal of Abnormal Child Psychology, 40(2), 211–223.CrossRefGoogle Scholar
  17. Decety, J., & Svetlova, M. (2012). Putting together phylogenetic and ontogenetic perspectives on empathy. Developmental Cognitive Neuroscience, 2(1), 1–24.CrossRefGoogle Scholar
  18. Domitrovich, C. E., Greenberg, M. T., Cortes, R., & Kusché, C. A. (2005). The preschool PATHS curriculum. Deerfield, MA: Channing-Bete.Google Scholar
  19. Edens, J. F., Mowle, E. N., Clark, J. W., & Magyar, M. S. (2017). “A psychopath by any other name?”: Juror perceptions of the DSM-5 “Limited Prosocial Emotions” specifier. Journal of Personality Disorders, 31(1), 90–109.CrossRefGoogle Scholar
  20. Ekman, P. (2002). Micro Expression training tool. San Francisco: University of California.Google Scholar
  21. Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37(1), 215–237.CrossRefGoogle Scholar
  22. Eyberg, S. M., & Pincus, D. (1999). Eyberg Child Behavior Inventory and Sutter-Eyberg Student Behavior Inventory—Revised: Professional manual. Odessa, FL: Psychological Assessment Resources.Google Scholar
  23. Fischer, L., & Blair, R. J. R. (1998). Cognitive impairment and its relationship to psychopathic tendencies in children with emotional and behavioral difficulties. Journal of Abnormal Child Psychology, 26(6), 511–519.CrossRefGoogle Scholar
  24. Forehand, R., Lafko, N., Parent, J., & Burt, K. B. (2014). Is parenting the mediator of change in behavioral parent training for externalizing problems of youth? Clinical Psychology Review, 34(8), 608–619.CrossRefGoogle Scholar
  25. Fowles, D. C., & Kochanska, G. (2000). Temperament as a moderator of pathways to conscience in children: The contribution of electrodermal activity. Psychophysiology, 37(6), 788–795.CrossRefGoogle Scholar
  26. Frick, P. J. (2004). The inventory of callous-unemotional traits. New Orleans, LA: University of New Orleans.Google Scholar
  27. Frick, P. J. (2012). Developmental pathways to conduct disorder: Implications for future directions in research, assessment, and treatment. Journal of Clinical Child & Adolescent Psychology, 41(3), 378–389.CrossRefGoogle Scholar
  28. Frick, P. J. (2013). Clinical assessment of prosocial emotions: Version 1.1 (CAPE 1.1). New Orleans, LA: University of New Orleans.Google Scholar
  29. Frick, P. J., Cornell, A. H., Barry, C. T., Bodin, S. D., & Dane, H. E. (2003). Callous-unemotional traits and conduct problems in the prediction of conduct problem severity, aggression, and self-report of delinquency. Journal of Abnormal Child Psychology, 31(4), 457–470.CrossRefGoogle Scholar
  30. Frick, P. J., & Nigg, J. T. (2012). Current issues in the diagnosis of attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder. Annual Review of Clinical Psychology, 8, 77–107.CrossRefGoogle Scholar
  31. Frick, P. J., Ray, J. V., Thornton, L. C., & Kahn, R. E. (2014). Can callous-unemotional traits enhance the understanding, diagnosis, and treatment of serious conduct problems in children and adolescents? A comprehensive review. Psychological Bulletin, 140, 1–57.CrossRefGoogle Scholar
  32. Frick, P. J., Stickle, T. R., Dandreaux, D. M., Farrell, J. M., & Kimonis, E. R. (2005). Callous-unemotional traits in predicting the severity and stability of conduct problems and delinquency. Journal of Abnormal Child Psychology, 33(4), 471–487.CrossRefGoogle Scholar
  33. Frick, P. J., & White, S. F. (2008). Research review: The importance of callous-unemotional traits for developmental models of aggressive and antisocial behavior. Journal of Child Psychology and Psychiatry, 49(4), 359–375.CrossRefGoogle Scholar
  34. Gray, C. A. (2000). Writing social stories with Carol Gray [Videotape and workbook]. Arlington, TX: Future Horizons.Google Scholar
  35. Haas, S. M., Waschbusch, D. A., Pelham, W. E., King, S., Andrade, B. F., & Carrey, N. J. (2011). Treatment response in CP/ADHD children with callous/unemotional traits. Journal of Abnormal Child Psychology, 39(4), 541–552.CrossRefGoogle Scholar
  36. Hawes, D. J., & Dadds, M. R. (2005). The treatment of conduct problems in children with callous-unemotional traits. Journal of Consulting and Clinical Psychology, 73, 737–741.CrossRefGoogle Scholar
  37. Hawes, D. J., Dadds, M. R., Frost, A. D., & Hasking, P. A. (2011). Do childhood callous-unemotional traits drive change in parenting practices? Journal of Clinical Child & Adolescent Psychology, 40(4), 507–518.CrossRefGoogle Scholar
  38. Hawes, D. J., Price, M. J., & Dadds, M. R. (2014). Callous-unemotional traits and the treatment of conduct problems in childhood and adolescence: A comprehensive review. Clinical Child and Family Psychology Review, 17(3), 248–267.CrossRefGoogle Scholar
  39. Hawes, S. W., Byrd, A. L., Waller, R., Lynam, D. R., & Pardini, D. A. (2017). Late childhood interpersonal callousness and conduct problem trajectories interact to predict adult psychopathy. Journal of Child Psychology and Psychiatry, 58(1), 55–63.CrossRefGoogle Scholar
  40. Kimonis, E. R., Bagner, D. M., Linares, D., Blake, C. A., & Rodriguez, G. (2014). Parent training outcomes among young children with callous–unemotional conduct problems with or at risk for developmental delay. Journal of Child and Family Studies, 23, 437–448.CrossRefGoogle Scholar
  41. Kimonis, E. R., Frick, P. J., Fazekas, H., & Loney, B. R. (2006). Psychopathy, aggression, and the processing of emotional stimuli in non-referred girls and boys. Behavioral Sciences & the Law, 24(1), 21–37.CrossRefGoogle Scholar
  42. Kimonis, E. R., Fanti, K. A., Anastassiou-Hadjicharalambous, X., Mertan, B., Goulter, N., & Katsimicha, E. (2016). Can callous-unemotional traits be reliably measured in preschoolers?. Journal of Abnormal Child Psychology, 44(4), 625–638.CrossRefGoogle Scholar
  43. Kimonis, E. R., Fleming, G., Briggs, N., Brouwer-French, L., Frick, P. J., Hawes, D. J., ... & Dadds, M. (2018). Parent-child interaction therapy adapted for preschoolers with callous-unemotional traits: An open trial pilot study. Journal of Clinical Child & Adolescent Psychology, 1–15.Google Scholar
  44. Kimonis, E. R., Frick, P. J., Munoz, L. C., & Aucoin, K. J. (2008). Callous-unemotional traits and the emotional processing of distress cues in detained boys. Development and Psychopathology, 20(2), 569–589.CrossRefGoogle Scholar
  45. Kochanska, G. (1993). Toward a synthesis of parental socialization and child temperament in early development of conscience. Child Development, 64, 325–347.CrossRefGoogle Scholar
  46. Kochanska, G. (1997). Multiple pathways to conscience for children with different temperaments: From toddlerhood to age 5. Developmental Psychology, 33, 228–240.CrossRefGoogle Scholar
  47. Kochanska, G., & Thompson, R. A. (1997). The emergence and development of conscience in toddlerhood and early childhood. In J. E. Grusec & L. Kuczynski (Eds.), Parenting and children’s internalization of values (pp. 53–77). New York, NY: Wiley.Google Scholar
  48. Lebowitz, M. S. (2016). Stigmatization of ADHD: A developmental review. Journal of Attention Disorders, 20(3), 199–205.CrossRefGoogle Scholar
  49. Longman, T., Hawes, D. J., & Kohlhoff, J. (2016). Callous–unemotional traits as markers for conduct problem severity in early childhood: A meta-analysis. Child Psychiatry & Human Development, 47(2), 326–334.CrossRefGoogle Scholar
  50. McGoron, L., & Ondersma, S. J. (2015). Reviewing the need for technological and other expansions of evidence-based parent training for young children. Children and Youth Services Review, 59, 71–83.CrossRefGoogle Scholar
  51. McMahon, R. J., Witkiewitz, K., Kotler, J. S., & Conduct Problems Prevention Research Group. (2010). Predictive validity of callous-unemotional traits measured in early adolescence with respect to multiple antisocial outcomes. Journal of Abnormal Psychology, 119(4), 752–763.CrossRefGoogle Scholar
  52. Miller, N. V., Haas, S. M., Waschbusch, D. A., Willoughby, M. T., Helseth, S. A., Crum, K. I., … Pelham, W. E. (2014). Behavior therapy and callous-unemotional traits: Effects of a pilot study examining modified behavioral contingencies on child behavior. Behavior Therapy, 45(5), 606–618.CrossRefGoogle Scholar
  53. Muñoz, L. C., Pakalniskiene, V., & Frick, P. J. (2011). Parental monitoring and youth behavior problems: Moderation by callous-unemotional traits over time. European Child & Adolescent Psychiatry, 20(5), 261–269.CrossRefGoogle Scholar
  54. Ospina, M. B., Seida, J. K., Clark, B., Karkhaneh, M., Hartling, L., Tjosvold, L., … Smith, V. (2008). Behavioural and developmental interventions for autism spectrum disorder: A clinical systematic review. PLoS One, 3(11), e3755.CrossRefGoogle Scholar
  55. Oxford, M., Cavell, T. A., & Hughes, J. N. (2003). Callous-unemotional traits moderate the relation between ineffective parenting and child externalizing problems. Journal of Clinical Child and Adolescent Psychology, 32, 577–585.CrossRefGoogle Scholar
  56. Pardini, D. A., Lochman, J. E., & Frick, P. J. (2003). Callous/unemotional traits and social-cognitive processes in adjudicated youths. Journal of the American Academy of Child & Adolescent Psychiatry, 42(3), 364–371.CrossRefGoogle Scholar
  57. Pardini, D. A., Lochman, J. E., & Powell, N. (2007). The development of callous-unemotional traits and antisocial behavior in children: Are there shared and/or unique predictors? Journal of Clinical Child and Adolescent Psychology, 36(3), 319–333.CrossRefGoogle Scholar
  58. Pasalich, D. S., Dadds, M. R., Hawes, D. J., & Brennan, J. (2012). Attachment and callous-unemotional traits in children with early-onset conduct problems. Journal of Child Psychology and Psychiatry, 53(8), 838–845.CrossRefGoogle Scholar
  59. Prasad, A. H., & Kimonis, E. R. (2018). Effects of the ‘Limited Prosocial Emotions’ specifier for conduct disorder on juror perceptions of juvenile offenders. Criminal Justice and Behavior. Scholar
  60. Reyno, S. M., & McGrath, P. J. (2006). Predictors of parent training efficacy for child externalizing behavior problems: A meta-analytic review. Journal of Child Psychology and Psychiatry, 47(1), 99–111.CrossRefGoogle Scholar
  61. Robinson, B. A., Azores-Gococo, N., Brennan, P. A., & Lilienfeld, S. O. (2016). The roles of maternal psychopathic traits, maternal antisocial personality traits, and parenting in the development of child psychopathic traits. Parenting, 16(1), 36–55.CrossRefGoogle Scholar
  62. Salekin, R. T., Worley, C., & Grimes, R. D. (2010). Treatment of psychopathy: A review and brief introduction to the mental model approach for psychopathy. Behavioral Sciences & the Law, 28(2), 235–266.CrossRefGoogle Scholar
  63. Shaffer, D., Fisher, P., Lucas, C. P., Dulcan, M. K., & Schwab-Stone, M. E. (2000). NIMH Diagnostic Interview Schedule for Children Version IV: Description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 39(1), 28–38.CrossRefGoogle Scholar
  64. Somech, L. Y., & Elizur, Y. (2012). Promoting self-regulation and cooperation in pre-kindergarten children with conduct problems: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 51(4), 412–422.CrossRefGoogle Scholar
  65. van Baardewijk, Y., Stegge, H., Bushman, B. J., & Vermeiren, R. (2009). Psychopathic traits, victim distress and aggression in children. Journal of Child Psychology and Psychiatry, 50(6), 718–725.CrossRefGoogle Scholar
  66. Vanderbilt Center on the Social and Emotional Foundations for Early Learning. (2013). Preschool training module: Module 2 social-emotional teaching strategies. Retrieved from
  67. Viding, E., Blair, R. J. R., Moffitt, T. E., & Plomin, R. (2005). Evidence for a substantial genetic risk for psychopathic traits in 7-year-olds. Journal of Child Psychology and Psychiatry, 46(6), 592–597.CrossRefGoogle Scholar
  68. Viding, E., Sebastian, C. L., Dadds, M. R., Lockwood, P. L., Cecil, C. A., De Brito, S. A., & McCrory, E. J. (2012). Amygdala response to preattentive masked fear in children with conduct problems: The role of callous-unemotional traits. American Journal of Psychiatry, 169(10), 1109–1116.CrossRefGoogle Scholar
  69. Waller, R., Gardner, F., & Hyde, L. W. (2013). What are the associations between parenting, callous–unemotional traits, and antisocial behavior in youth? A systematic review of evidence. Clinical Psychology Review, 33(4), 593–608.CrossRefGoogle Scholar
  70. Waller, R., Gardner, F., Viding, E., Shaw, D. S., Dishion, T. J., Wilson, M. N., & Hyde, L. W. (2014). Bidirectional associations between parental warmth, callous unemotional behavior, and behavior problems in high-risk preschoolers. Journal of Abnormal Child Psychology, 42(8), 1275–1285.CrossRefGoogle Scholar
  71. Wootton, J. M., Frick, P. J., Shelton, K. K., & Silverthorn, P. (1997). Ineffective parenting and childhood conduct problems: The moderating role of callous-unemotional traits. Journal of Consulting and Clinical Psychology, 65, 301–308.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.School of PsychologyThe University of New South WalesSydneyAustralia

Personalised recommendations