Treatment of Childhood Disruptive Behaviour Disorders and Callous-Unemotional Traits

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In this Papers Podcast, Samantha Perlstein discusses her co-authored JCPP paper ‘Treatment of childhood disruptive behavior disorders and callous-unemotional traits: a systematic review and two multilevel meta-analyses’ ( Samantha is the first author of the paper.

Discussion points include:

  • Definition of disruptive behaviour disorders and callous-unemotional traits.
  • The main research questions in this study.
  • The research gaps that the study tried to address.
  • Implications from a researcher, and practitioners’, perspective.

In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP)The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.

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Samantha Perlstein
Samantha Perlstein

Samantha Perlstein is a doctoral candidate in the clinical psychology program at the University of Pennsylvania. She received her MA in psychology at the University of Pennsylvania and her BA in Psychology and Human Rights from Barnard College. She is a NIH Postbaccalaureate Intramural Research Training Award Recipient and worked in the Section for Mood Dysregulation and Neuroscience prior to matriculating to the University of Pennsylvania. Her research explores the development of antisocial and psychopathic behaviors in childhood, including a focus on the psychological and neurocognitive processes that underpin deficits in empathy and social bonding in children with callous-emotional traits.

Other resources

  • Featured paper ‘Treatment of childhood disruptive behavior disorders and callous-unemotional traits: a systematic review and two multilevel meta-analyses’, Samantha Perlstein, Maddy Fair, Emily Hong, Rebecca Waller


[00:00:01.400] Mark Tebbs: Hello, and welcome to Papers Podcast series for the Association of Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, Freelance Consultant. In this series, we speak to the authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, Child and Adolescent Mental Health, known as CAMH, and JCPP Advances. If you’re one of the fans of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating review, and do share with friends and colleagues.

Today, I’m interviewing Samantha Perlstein, who is the lead author with Maddy Fair, Emily Hong and Rebecca Waller of a paper entitled, “Treatment of Childhood Disruptive Disorders and Callous Emotional Traits: A Systematic Review and Two Level Meta-Analyses.” Samantha is a Doctoral candidate in the Clinical Psychology Program at the University of Pennsylvania. Samantha, thank you for joining me. Really looking forward to our conversation today.

[00:01:03.829] Samantha Perlstein: Yes, thank you for having me.

[00:01:05.379] Mark Tebbs: Let’s start with some introductions. So, could you just say who you are and a little bit about your career to date?

[00:01:10.670] Samantha Perlstein: So, I am in my fifth year, a Doctoral candidate at the University of Pennsylvania in the Clinical Psychology Program here. Very broadly, my research, to date, has focused on understanding both the aetiology and the heterogeneity within the development of childhood antisocial behaviour. The ultimate goal is to identify novel targets for early intervention, early identification. So, that’s been, kind of, the focus of my work.

[00:01:39.520] Mark Tebbs: Great stuff. So, let’s turn to the paper, could you just start by, maybe, just giving like a brief overview of the kind of broad paper, please?

[00:01:47.610] Samantha Perlstein: Yeah, of course. So, the paper was the culmination of a couple of multilevel meta-analyses just aimed at really synthesising the current state of the literature on treatment for childhood disruptive behaviour disorders. Specifically those with high levels of callous-unemotional traits. We really wanted to determine whether or not the current treatments that we had were affective for kids who were displaying these high levels of CU traits.

[00:02:16.200] Mark Tebbs: I think, maybe, before we go on any further, it would be really useful just to define a few of those key terms. So, could you define disruptive behaviour disorders and, maybe, callous-unemotional traits? I don’t know if there’s any other terms that would be useful, just to come back a little bit.

[00:02:32.390] Samantha Perlstein: Yeah, of course, it’s a lot of terminology and a lot of alphabet soup. But disruptive behaviour disorders, so, basically, it’s a category of disorders that includes both oppositional defiant disorder, or ODD, and conduct disorder. Those are, kind of, two of the big hallmark disorders in that category. And these are disorders in which children show a pattern of defiant, unco-operative, aggressive and other types of antisocial behaviours that, ultimately, just impact their daily functioning and those around them.

And then, on the other hand, callous-unemotional traits, or CU traits, characterises a temperament style of both callous, uncaring and remorseless affect. Typically, these kids are showing really low empathy, really low guilt, and a lot of interpersonal callousness, and we know that children who display CU traits are at a greater risk of a life-long pattern of antisocial behaviour. And so, understanding, you know, children who might display disruptive behaviour disorders, who have CU traits, it’s really important to think about this subgroup and what we can do to, potentially, head off that long-term pattern.

[00:03:37.420] Mark Tebbs: So, what was it that you was trying to understand? What were the research questions that you set out with and what were the research gaps, maybe, you were trying to address?

[00:03:47.560] Samantha Perlstein: So, research on callous-unemotional traits, or CU traits, in children has been ongoing for a few decades now. A lot of early work came from Researchers like Dr Paul Frick and colleagues. And a lot of that research was born from a downward extension of the adult features of psychopathy, and taking that within a more development framework. A lot of research has also shown that children with CU traits have, maybe, a distinct genetic or biological profile, it’s a little bit more heritable than other forms of, kind of, antisocial behaviour that you might see. And so, this, combined with the historical origins of this psychopathy extension, has led to a lot of therapeutic nihilism. So, thinking that these kids can’t be treated, that this is just, you know, the way that they are, and a lot of Clinicians, maybe, being really wary of treating these kids.

And so, we, as a research team, wanted to really understand, you know, the current treatments that we have for disruptive behaviour disorders, are they actually affective for kids with CU traits? That’s, kind of, question one. So, would we actually see kids with high levels of CU traits, would they also show decreases in disruptive behaviours on, like, things like aggression, similar to those who don’t have the CU traits? And, then, on the flipside, was then to understand, can these treatments actually affect CU traits themselves? Could we actually see a reduction in these very specific, like, temperament characteristics, following treatment? So, that was kind of the two-pronged approach that we took with this project.

[00:05:21.300] Mark Tebbs: So, yeah, really important questions. So, how did you go about the study, and were there any particular metalogical challenges that you had to overcome?

[00:05:31.460] Samantha Perlstein: Yeah, I think whenever you embark on a quantitative synthesis, or any kind of synthesis of the research literature, defining your terms is always really, really important, and making sure that you, kind of, have a clear set going in. You know, what are these things that we’re talking about? And then, the other piece was, what’s the best way to synthesise this? And so, what we, kind of, discovered is that, especially when it comes to disruptive behaviour, this is termed a very different way across the literature.

So, some people are looking at aggression, some people are looking at defiance, some people are looking at, like, criminal activity, things like that, and they kind of look at that as treatment targets. So, something that we wanted to do is, to really make sure we could take all of the different affects, all the different ways of measuring this, and incorporate this into our meta-analyses. So, that’s the multilevel aspect of the meta-analysis, because within a given study, you might have multiple different treatment affects that you’re looking at.

So, we want to be able to acknowledge the fact that these are nested within a study, within a paper, but they might also be different affects. So, that allowed us to really take everything that we could from these studies and put them into our analysis. So, that was a big challenge, but I think, ultimately, the biggest challenge came from the fact that there’s not a lot of very rigorous studies, randomised controlled trial studies that are comparing a treatment group to a control group on the effect of things like CU trait. It’s still a relatively new area in the field, and, so, we weren’t able to include as many studies as we would have liked in our analysis, ultimately, because they weren’t really doing this, like, comparison and control design.

[00:07:09.040] Mark Tebbs: So, what did the study find? What were the key findings from your work?

[00:07:13.020] Samantha Perlstein: The first big finding that I think might not really come to a surprise to people who, maybe, are actually working with these children, was that we found that children with high levels of CU traits, versus those with lower levels of CU traits, these children with high CU traits started treatment with more symptoms, more disruptive behaviour symptoms. So, the severity was higher, and then they ended treatment with more symptoms than their low CU trait counterparts.

However, the change was still there, so the rate of change, the amount of change was still the same. So, these kids were improving with treatment, their symptoms were going down, they just weren’t catching up to their low CU trait counterparts, and, again, that might be because they’re starting treatment with more symptoms. So, that was encouraging for us to find, but it also did suggest that, maybe, we need to do a bit more for these kiddos. So, that was the finding one.

Finding two was that, when we were just looking at studies that had this more rigorous treatment versus control condition, we didn’t really see an effective treatment on the CU traits themselves. In moderation analyses that we did, we determined that there was a small affect when you looked at treatments that had a parent training component, so, a component of treatment that involved the parents, and involved teaching parents new skills. How to interact with their kids, how to respond to child behaviour problems. Treatments that incorporated that piece versus ones that did not, they did have a small effect on reducing CU traits themselves. It was small, but it was there, so, that was also encouraging.

[00:08:44.710] Mark Tebbs: Okay, so it would be really useful for us to think about what some of the implications of those important findings are. So, starting with, like, a – from a research perspective?

[00:08:54.570] Samantha Perlstein: I think – this is something I hinted at earlier, but the need for more rigorous treatment design. So, really going in and really putting like a head-to-head test of giving a child, you know, this treatment versus, maybe, a weightless control, or, maybe, just going in community referrals, and really seeing, can we see a direct effect of the treatment, when we’re actually controlling for whether or not they’re receiving it or not? So, that is the one piece, is we need that.

We, also need to think carefully, and people are already out in the field doing this, which is really exciting, but, thinking carefully about what are some specialised interventions or that extra modules we might be able to provide families that can help push the gap and get these kids a little bit closer to their low CU trait counterparts when treatment finishes. So, those are, kind of, some of the big pieces, is kind of more work, I think that’s always the answer.

[00:09:50.300] Mark Tebbs: Yeah, that is always the answer, isn’t it, there’s always more to do. I’m just wondering, sort of, from a here and now perspective, so, if there’s practitioners in the field that are listening, so are there any implications, from your study, that you could share?

[00:10:04.260] Samantha Perlstein: Yeah, yeah, for sure. I think the first big piece is to acknowledge that, you know, these kids are coming in with more symptoms. So, there is a severity component there and practitioners are not wrong in seeing that it might be a little bit more challenging, so, I do want to acknowledge that piece of it. But, I think, the other side of it is, we can still be really helpful, and I think that that is an important takeaway. That the treatments that we have they’re doing something, they’re still providing benefit, so that’s good to hear. So, that piece, and then, there is some evidence now, and I think my study, along with many others, have hinted that this parent component might be particularly important. So, ensuring that we have some sort of parent training, parent support for families, can really go a long way.

[00:10:52.290] Mark Tebbs: And you mentioned some other research that’s happening in the field, I wonder whether you’ve got any further fallout research that you’re planning or any, like, work you’d like to share that you’ve got in the pipeline?

[00:11:03.070] Samantha Perlstein: I think something that I’m particularly interested in, from a research perspective is, this early identification and opportunity for early intervention. And I think there are a lot of areas in the field of child mental health where we do take this approach. I think when you look at the autism literature, there’s a lot of work on early identification and early intervention that has been shown to be really helpful, but I don’t think we have the same approach when it comes to other aspects of mental health.

So, a big goal of mine, and a current study that I’m working on, is looking at early social emotional deficits, and whether or not these can predict out to CU traits, and then, also, whether or not we can look at other parenting factors that can help buffer any negative effects of some early deficits.

So, I have a previous study that I had published, where we saw that early social emotional deficits at age two predicted CU traits at age three, and that was a really interesting study. I think that really pointed to this as a potential early identifier. Of course, social emotional deficits is a risk factor for a lot of different types of disorders, but I think, thinking about it from this lens, is something that could be really helpful when we’re thinking about, potentially, heading off all sorts of mental health problems, including CU traits.

[00:12:21.660] Mark Tebbs: What was the name of the study? Is there a place where listeners could get hold of the study?

[00:12:27.370] Samantha Perlstein: Yeah, so the study is called, “Low Social Affiliation Predicts Increases in Callous-Unemotional Behaviours in Early Childhood,” and it was actually published in JCPP, so the same journal.

[00:12:40.210] Mark Tebbs: And that’s great, we’ll include a link to the transcript in this podcast. We’re coming to the end of the podcast, so I’m just wondering whether you’ve got any take home messages for the listeners?

[00:12:51.400] Samantha Perlstein: I guess repeating, maybe, something I’ve said before, it’s just that, you know, we can still provide a lot of help to these families and we can definitely get kids in the place where they need to be and support them with the tools that we have currently. I think that there’s still a lot of great work that we have to do, but I think that we should feel pretty optimistic.

[00:13:14.589] Mark Tebbs: Great stuff. Thank you so much for your time, Samantha, it’s been a really interesting podcast. For more details on Samantha, please visit ACAMH website,, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating review, and do share with friends and colleagues.

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