Practitioner Review: Involving young people with callous unemotional traits in treatment - Does it work? A systematic review

Abstract

Background Children and adolescents with callous unemotional (CU) traits are at risk of severe and persistent antisocial behavior. It is commonly assumed that these children are difficult to treat but it has been proposed that they may benefit from being involved in interventions that go beyond typical parent training programs. This systematic review sought to answer two previously unanswered questions: do interventions involving young people reduce levels of CU traits? Do CU traits predict the effectiveness of interventions for antisocial behavior involving young people? Method Studies were included that adopted an randomized controlled trial, controlled or open trial design and that had examined whether treatment was related to reductions in CU traits or whether CU traits predicted or moderated treatment effectiveness. Results Treatments used a range of approaches, including behavioral therapy, emotion recognition training, and multimodal interventions. 4/7 studies reported reductions in CU traits following treatment. There was a mixed pattern of findings in 15 studies that examined whether CU traits predicted treatment outcomes following interventions for antisocial behavior. In 7/15 studies, CU traits were associated with worse outcomes, although three of these studies did not provide data on baseline antisocial behavior, making it difficult to evaluate whether children with high CU traits had shown improvements relative to their own behavioral baseline, despite having the worst behavioral outcomes overall. CU traits did not predict outcomes in 7/15 studies. Finally, a single study reported that CU traits predicted an overall increased response to treatment. Conclusions Overall, the evidence supports the idea that children with CU traits do show reductions in both their CU traits and their antisocial behavior, but typically begin treatment with poorer premorbid functioning and can still end with higher levels of antisocial behavior. However, there is considerable scope to build on the current evidence base. This paper is the first systematic review of the evidence for individual-focused interventions for antisocial behavior in young people with callous unemotional (CU) traits. Whilst a review of parenting interventions for children with CU traits has been carried out (Waller et al., Clinical Psychology Review, 33, 2013, 593), there has been no previous review of interventions involving direct work with young people. Given that parenting interventions are not always successful and do not have a strong evidence base based on studies of older children and adolescents, we think that it is important to provide a clear overview regarding individual-focused treatments. We think that such a review is particularly timely, given the DSM-5 CU traits specifier and the unfortunate, but widely held belief, that treatment is likely to be less successful in children with CU traits. We ask two questions in our review. First, we asked whether individual-focused interventions directly reduce levels of CU traits? Second, we asked whether CU traits predict the effectiveness of individual-focused interventions for antisocial behavior? The extant evidence certainly suggests that whilst children with CU traits typically display more severe antisocial behavior, there are treatments that work to reduce both CU traits and antisocial behavior in these children. Interventions tailored to address specific areas of difficulty for children with CU traits may be particularly effective and we argue that further randomized controlled trials of tailored interventions such as behavioral therapy, CBT, interventions designed to increase positive emotion and emotion recognition training are needed.