• Lynn Cukaj

Conduct Disorder: Youth & Adolescents

Milone et al. (2019) explored the relationships between callous-unemotional traits (CU), cognitive and emotional empathy, emotion recognition, and history of maltreatment in a sample of 60 Italian male patients with a diagnosis of conduct disorder (CD).

Empathy is multifaceted and begins in the early stages of life.

As a teacher of preschoolers and an art therapist to school age children, I would agree that as young as 2, one can see the presence of both affective and cognitive empathy. This article cites many studies about the relation of affective and cognitive empathy to callous unemotional traits. This specifier in the diagnosis of conduct disorder I find very interesting because I would think most children/adolescents who receive this diagnosis would exhibit some level of callous unemotional traits.

Callous-unemotional traits are a specifier in the diagnosis of conduct disorder which must be:

  • present for 12 months or more

  • in more than one setting, and

  • demonstrate two or more of the following: lack of remorse or guilt, lack of empathy, unconcerned about performance, and shallow or deficient affect (Milone et al., 2019, p. 2).

Milone et al. (2019) discuss what empathy is, how it develops, and what studies have been done to discuss pro-social behaviors and the development of empathy. One of the interesting points Milone et al. (2019) make is that reduced eye contact by the caregiver may be a contributing factor in the lack of development of empathy and these studies have been used to create parent training programs. There seems to be conflictual information about how empathy is developed when negative experiences such as maltreatment are experienced by a child/adolescent. I would tend to agree that studies would have inconclusive evidence in this area because of a person’s innate or inability to be resilient. In my experience and now learning more about trauma and PTSD, even as few as two people experiencing similar negative experiences will have differing outcomes of resiliency. Therefore, children raised in an abusive/neglectful household would not have the same outcome in their mental health. Milone et al. (2019) state that the pathways to developing conduct disorder with high callous unemotional traits are complex with the need for genetic and environmental factors to be considered as well.

Milone et al. (2019) stated that most of the studies examining CU traits and the relationship it has with a lack of empathy were not done where the sample already had a diagnosis of conduct disorder (as in the current study) but in at-risk community samples. What I found the most intriguing was the differentiation of cognitive empathy versus affective empathy. In my opinion it makes complete sense that a child/adolescent that has a high level of CU traits would have limited affective empathy but high or intact cognitive empathy. Cognitive empathy essentially is understanding the emotional states and thoughts of others and affective empathy is being impacted/moved by that understanding. It would seem reasonable to me that individuals with conduct disorder and high levels of CU could understand a person’s thoughts and feelings but they just would not care, demonstrating a lack of compassion and concern. However, Milone et al. (2019) found several emotion recognitions studies that dispute that cognitive empathy is not affected with a CD and CU trait diagnosis.

The current study was not only going to examine the CU traits and the impact on empathy (cognitive and affective) but also emotional recognition. Then, how does maltreatment specifically early difficulties in the parent-child relationship impact the development of CD. I found this part fascinating because I would say yes that maltreatment in early bonding would negatively impact a child. However, I have attended workshops over the years about the role of resiliency and trauma and that some children do not develop mental health issues with maltreatment while others do and these studies look at the role of resiliency. This study did not discuss this aspect. Milone et al. (2019) concluded that maltreatment did not correlate to empathy or CU traits. It was stated that high CU traits may result in harsher parenting style rather than harsh parent style being the cause of the CU traits. And then I thought, can a child be born bad? Without a conscience? I have worked with children as young as three years old who demonstrate no empathy and as a teacher/therapist it is my job to use pro-social skill training with these children. So, I do believe to a certain extent there is a complexity of genetic and environmental factors that lead a youth to develop CD with CU traits.

I felt that the most interesting part of the study was the information about empathy and the differences in cognitive and affective empathy. It makes sense to me that individuals with CD and CU traits would not have an impairment in cognitive empathy and but would have low levels of affective empathy Milone et al. (2019) showed that CD youths with CU traits have low levels of affective empathy but no significant impairment in cognitive empathy. Milone et al. (2019) cite other studies that show inclusive findings in regard to findings of cognitive empathy and the relationship to CD with CU traits but it seems that most studies agree that youths with CD and CU traits have low levels of affective empathy.

In this type of psychopathology being able to recognize and understand another person’s feelings (specifically fear and sadness) while not caring about it, would allow for CD behaviors to exist and then would explain how those with CD as children/adolescent develop anti-social personality disorder. That the ability to not care in CD youth with CU traits would develop into an ego syntonic personality trait rather than ego dystonic. Milone et al. (2019) cite further research in emotion recognition and correlation to those youths with high levels of CU traits. Milone et al. (2019) discuss clinical implications for treatment and the need for a larger sample to confirm the results of the study. For me as a teacher/therapist, I found the study to be an interesting and complicated read.

Learn more about Art Therapy and Lynn Cukaj, Board Certified Art Therapist here: www.CreativeExpressionsConsulting.com


Milone, A., Cerniglia, L., Cristofani, C., Inguaggiate, E., Levantini, V., Masi, G., Paciello, M.,

Simone, F., & Muratori, P. (2019). Empathy in youths with conduct disorder and callous-unemotional traits. Neural Plasticity, https://doi.org/10.1155/2019