Annual Review of Clinical Psychology

Conduct Disorders and

Empathy Development
Paul J. Frick1,2 and Emily C. Kemp1
1
Department of Psychology, Louisiana State University, Baton Rouge, Louisiana 70803, USA;
email: pfrick@lsu.edu, ekemp4@lsu.edu
2
Institute for Learning Sciences and Teacher Education, Australian Catholic University,
Brisbane 4001, Australia

Annu. Rev. Clin. Psychol. 2021. 17:391–416 Keywords

First published as a Review in Advance on
empathy, callous-unemotional traits, CU traits, conduct disorders,
December 8, 2020
parenting, aggression, treatment
The Annual Review of Clinical Psychology is online at
clinpsy.annualreviews.org Abstract
https://doi.org/10.1146/annurev-clinpsy-081219-
Childhood conduct disorders, a serious mental health concern, put children
105809
at risk for significant mental health problems throughout development. El-
Copyright © 2021 by Annual Reviews.
evations on callous-unemotional (CU) traits designate a subgroup of youth
All rights reserved
with conduct disorders who have unique causal processes underlying their
problem behavior and are at a particularly high risk for serious impairment
relative to others with these disorders. As a result, these traits have recently
been integrated into major diagnostic classification systems for conduct dis-
orders. Given that CU traits are partly defined by deficits in empathy, we re-
view research on empathy development in typically developing children and
use this research to (a) advance theories on the specific emotional deficits
that may be associated with CU traits, (b) explain the severe pattern of ag-
gressive behavior displayed by children with elevated CU traits, and (c) sug-
gest possible ways to enhance prevention and treatment for children with
conduct disorders and elevated CU traits.

391
 Contents
A BRIEF INTRODUCTION TO CONDUCT DISORDERS . . . . . . . . . . . . . . . . . . . . . 392
MULTIPLE DEVELOPMENTAL PATHWAYS TO CONDUCT DISORDER . . . 393
OVERVIEW OF EMPATHY DEVELOPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Affective Versus Cognitive Empathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Timing of Empathy Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
Temperament and Parenting in the Development of Empathy . . . . . . . . . . . . . . . . . . . . . 399
Empathy in Broader Developmental and Psychopathological Constructs . . . . . . . . . . . 400
INTEGRATING RESEARCH ON CONDUCT DISORDERS
AND EMPATHY DEVELOPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Clarifying the Emotional Deficits Associated with Callous-Unemotional Traits . . . . 401
Explaining the Association Between Callous-Unemotional Traits
and Aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
IMPLICATIONS FOR TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406

A BRIEF INTRODUCTION TO CONDUCT DISORDERS

Childhood disruptive behaviors or conduct problems have been distinguished from “internaliz-
ing problems” (i.e., anxiety and depression) in the classification of childhood psychopathology for
several decades (Achenbach & Edelbrock 1978). While this broad distinction between internal-
izing and externalizing problems has been widely supported, there has been less consensus over
whether meaningful distinctions can be made within disruptive behaviors. Distinctions have been
made between (a) aggressive and nonaggressive and/or rule-breaking behaviors (Burt wet al. 2015),
(b) overt and covert behavior problems (Frick et al. 1993), and (c) oppositional-defiant behaviors
and conduct disorder symptoms, the latter of which are defined by violations of others’ rights
and/or major societal norms and rules (Frick & Nigg 2012). Each of these distinctions has some
proven validity for distinguishing groups of children and adolescents with conduct problems that
may differ in etiology, severity, and course (for a review, see Frick & Matlasz 2018).
However, research has also shown that the different types of disruptive behaviors tend to be
substantially intercorrelated and often form a single externalizing factor in multivariate studies
(Lahey et al. 2008). Further, children and adolescents who show the most impairing patterns of
disruptive behavior often show behaviors across the various subdimensions (e.g., both aggres-
sive and nonaggressive behaviors or both oppositional-defiant and conduct disorder symptoms)
(Frick & Nigg 2012). In addition, behavioral genetic research has consistently shown strong shared
genetic influences across the disruptive behaviors (Lahey et al. 2011, 2017). Consequently, the
Conduct disorder:
a pattern of severe, fifth and most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
nonnormative, and groups Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) into a category of
impairing conduct disorders called the Disruptive, Impulse Control, and Conduct Disorders (Am. Psychiatr. Assoc.
problems that can fall 2013).
within the DSM-5
For the purposes of this review, we refer to severe and impairing levels of these disrup-
categories of
Oppositional Defiant tive behaviors as conduct disorders, which include the DSM-5 categories of ODD and CD.
Disorder or Conduct These conduct disorders constitute a significant mental health concern. They affect 5.7% of
Disorder children worldwide (Canino et al. 2010) and lead to over half (57%) of all referrals of children
to mental health services in the United States, with the next most common referral being for

392 Frick • Kemp

attention-deficit/hyperactivity disorder at 38.5% (SAMHSA 2010). In strictly financial terms, it
has been estimated that each child with a conduct disorder costs $70,000 more than a typically
developing child from ages 7 to 13 in costs from mental health and medical services, special edu-
cation services at school, and contact with the juvenile justice system (Foster et al. 2005). Conduct
disorders can also lead to many other mental health problems across development, including anxi-
ety, depression, suicidality, and substance abuse (Odgers et al. 2008). As a result, conduct disorders
are often considered one of the most robust childhood predictors of risk for mental health prob-
lems later in life (Burt et al. 2018). Conduct problems in early childhood also substantially increase
risk for a number of other problems in adulthood, including medical illnesses, poorer marital ad-
justment, lower educational attainment, school dropout, and criminality (Odgers et al. 2007).
As with most forms of psychopathology, the symptoms of conduct disorders are present to some
degree in typically developing individuals. For example, frequent oppositional behavior is quite
prevalent in preschool children (Keenan 2012, Wakschlag et al. 2007). Similarly, multiple studies
have shown that physical aggression is quite common in preschool children and that overall levels
of aggressive behavior decrease throughout childhood and adolescence (Tremblay 2010). Further,
studies have shown that some level of norm- and rule-breaking is common in adolescents (Brezina
& Piquero 2007). Thus, definitions of conduct disorders must consider methods for distinguishing
disordered behaviors from normative or nondisordered ones, such as when behaviors are more
severe than would be expected for a child’s age, when they occur in multiple situations and settings,
and/or when they cause impairment for the child (Frick & Nigg 2012).
This discussion makes it clear that the distinction between normal and disordered behavior is
often based on heuristic cutoffs that help to determine when a child may need treatment but that
may not reflect true differences in the underlying causes of behavior. That is, the presence of a
disorder may not reflect the presence of a pathological process unique to disordered individuals
that is not present in nondisordered individuals. We have argued that, as a result, it is important to
consider normal developmental processes that may go awry in leading a child to display a conduct
disorder (Frick & Viding 2009). Specifically, conduct disorders reflect a child’s inability to regulate
their emotions and behaviors, which is likely why they are predictive of so many problems in
adjustment throughout the life span. In our view, the presence of a conduct disorder indicates
that some developmental process through which a child learns to regulate their emotions and
behaviors is impaired. Thus, it is important to consider the key developmental processes through
which children normally develop self-regulation, to understand how they may go awry in children
with conduct disorders.

MULTIPLE DEVELOPMENTAL PATHWAYS TO CONDUCT DISORDER

The primary focus of this review is on one specific process that research suggests is important for
the development of self-regulation: the healthy development of empathic concern toward others.
However, before discussing empathy and its relevance to conduct disorders, it is important to rec-
ognize that the causes of conduct disorders likely involve multiple processes that differ across indi-
viduals with the same disorder. While the DSM-5 explicitly defines all disorders in the category of
Disruptive, Impulse Control, and Conduct Disorders as involving problems with self-regulation
(i.e., emotional and behavioral control), it recognizes that the causes of self-control problems can
vary (a) across disorders included in the category and (b) among individuals with the same di-
agnosis (Am. Psychiatr. Assoc. 2013). Further, research has provided very clear and convincing
evidence for the presence of several common causal pathways that can lead to these problems in
self-control, with only one pathway clearly involving deficits in empathic concern for others.

www.annualreviews.org • Conduct Disorders and Empathy Development 393

 One causal pathway that has long been recognized in research on both conduct disorders and
juvenile delinquency helps to explain why a number of youth start showing behavior problems as
they approach adolescence (Fairchild et al. 2013, Moffitt 2018). This group accounts for almost
Callous-unemotional
(CU) traits: specifier half of all adolescents who display conduct disorders, and, compared with children who start show-
for a unique subgroup ing conduct problems earlier in childhood, members of this group are less likely to be aggressive
of youth with conduct and less likely to continue to show antisocial and criminal behavior into adulthood (Moffitt 2018,
disorders defined by Odgers et al. 2008). Youth with adolescent-onset conduct disorders are also less likely to show a
callous lack of
number of dispositional [e.g., impulsivity, poor emotional regulation, callous-unemotional (CU)
empathy, deficient
guilt/remorse, lack of traits] and environmental (e.g., hostile parenting) risk factors compared with children who start
concern over showing behavior problems in childhood (Fairchild et al. 2013, Frick & Viding 2009). Further,
performance in when youth within the adolescent-onset group differ from control children without conduct dis-
important activities, orders, it is often in their displays of higher rebelliousness and rejection of conventional values and
and constricted display
status hierarchies (Dandreaux & Frick 2009, Moffitt et al. 1996). On the basis of these findings,
of emotion
youth who follow the adolescent-onset pathway are often conceptualized as showing an exagger-
ation of the normative process of adolescent rebellion (Moffitt 2018). That is, rebelliousness is
part of a process by which the adolescent begins to develop their autonomous sense of self and
unique identity by rebelling against traditional authority figures, such as parents. According to
Moffitt (2018), the child in the adolescent-onset group engages in antisocial and delinquent be-
haviors as a misguided attempt to obtain a subjective sense of maturity and adult status in a way
that is maladaptive (e.g., breaking societal norms) because of (a) encouragement by an antisocial
peer group, (b) lack of bonding to prosocial institutions, (c) poor supervision by parents, and/or
(d) a rebellious personality (see also Frick & Viding 2009). Given that their behavior is viewed
as an exaggeration of a process specific to adolescence, and not due to an enduring vulnerability,
their antisocial behavior is less likely to persist beyond adolescence. However, for some of these
youth in the adolescent-onset group, the consequences of their adolescent antisocial behavior may
persist into adulthood (e.g., a criminal record, dropping out of school, substance abuse) (Moffitt
2018).
In short, the developmental process that seems important for understanding the adolescent-
onset pathway involves difficulties with identity formation. In contrast, it appears that persons
who follow the childhood-onset pathway show more characterological disturbances that begin
earlier and lead to problems across multiple developmental stages. Specifically, children in the
childhood-onset group often begin showing mild conduct problems (e.g., oppositional behavior,
temper tantrums) early in childhood, and their behavioral problems tend to increase in rate and
severity throughout childhood and into adolescence (Frick & Viding 2009). As noted above, the
childhood-onset group is more likely to show aggressive behaviors in childhood and adolescence,
to show antisocial and criminal behavior that continues into adulthood, and to show more dispo-
sitional and contextual risk factors than the adolescent-onset group (Fairchild et al. 2013, Frick &
Viding 2009). Thus, this group is often viewed as developing problem behaviors through a trans-
actional process involving a difficult and vulnerable child (e.g., fearless, impulsive, with verbal
deficits) who experiences an inadequate rearing environment (e.g., poor parental supervision, low
parental warmth, poor-quality schools) (Moffitt 2018). This dysfunctional transactional process
disrupts the child’s socialization, leading to poor social relations with persons both inside (e.g.,
parents, siblings) and outside (e.g., peers, teachers) the family. Furthermore, these disruptions
can lead to enduring vulnerabilities that may negatively affect the child’s psychosocial adjustment
across the life span.
Recent research suggests that an important distinction can be made within this childhood-
onset group. One group within the childhood-onset pathway is more likely to show high levels of
emotional reactivity, poor impulse control, lower verbal intelligence, and a hostile attribution bias

394 Frick • Kemp

through which they tend to perceive peers’ behavior as provocative (Frick & Viding 2009). As a
result, these children tend to show high levels of impulsive anger and aggression in response to
perceived provocations from others (Frick et al. 2003b, Lawing et al. 2010). Further, this group of
Psychopathy:
children and adolescents with conduct disorders shows behavior problems that are highly related personality construct
to hostile and coercive parenting (Pasalich et al. 2011, Wootton et al. 1997). Thus, it appears that designating a subset of
these children with childhood-onset conduct disorders show problems regulating their emotions antisocial adults that
and behaviors due to a temperament characterized by strong emotional reactivity and other dispo- signals the presence of
distinct etiological
sitional tendencies (e.g., limited verbal abilities) that, when combined with inadequate socializing
mechanisms and
experiences, lead to problems regulating their emotions and behavior (Frick & Morris 2004). increased risk for more
Importantly, children in this dysregulated pattern of conduct disorders are often highly dis- chronic and severe
tressed by the effects of their behavior on others and, in fact, frequently show high rates of anxiety forms of antisocial
in addition to their conduct problems (Frick & Viding 2009). Thus, a deficit in empathic concern behavior
for others does not appear to be a primary causal factor for their conduct disorders. However,
other persons with childhood-onset conduct disorders display a lack of distress in response to
the effects of their behavior on others, and this pathway is defined by the presence of elevated
CU traits (Frick et al. 2014b). One key indicator of CU traits is a callous lack of empathy to-
ward others. Other indicators of this construct include lack of guilt, absence of effort to do well
in important activities, and constricted or superficial displays of emotion (Frick & Ray 2015).
Further, CU traits were a core component (i.e., the affective facet) of early clinical descriptions
of psychopathy (Cleckley 1976, Hare 1993) and were part of the definition of the “undersocial-
ized” subtype of conduct disorders in earlier versions of the DSM [e.g., DSM-III (Am. Psychiatr.
Assoc. 1980)].1
Because of significant debate over the core features of CU traits and whether they could be as-
sessed reliably, these traits were dropped from editions of the DSM starting in 1987 (DSM-III-R)
(Am. Psychiatr. Assoc. 1987). However, over the last three decades, substantial research has refined
the core features of CU traits (Frick & Ray 2015) and shown that they can be reliably assessed
in children as young as 2 years of age (Kimonis et al. 2016). More importantly, CU traits have
proven critical for designating a subgroup (approximately 25–30%) of children with childhood-
onset conduct disorders who differ in clinically and theoretically important ways from other youth
with conduct disorders (Kahn et al. 2013). Comprehensive reviews of this research can be found
elsewhere (Blair et al. 2014, Frick et al. 2014b). Below, we summarize some of the key characteris-
tics of children with conduct disorders and elevated CU traits that differentiate them from other
children with these disorders:
 The conduct problems of children with elevated CU traits tend to be more severe, aggres-
sive, and stable (see, e.g., Frick et al. 2003a, Lawing et al. 2010, McMahon et al. 2010).
 Children with elevated CU traits tend to respond less well to traditional mental health treat-
ments for conduct disorders, often starting treatment with more severe behavior problems
and, while improving with treatment, still showing more severe behavior problems after
treatment (see, e.g., Hawes & Dadds 2005, White et al. 2013).
 Conduct problems accompanied by elevated CU traits show larger heritable influences (see,
e.g., Viding et al. 2005, 2007), which may be due to significant loci involving the serotonin
and oxytocin systems (for a review, see Moore et al. 2019).

1 Psychopathy is generally defined as a constellation of chronic and impairing interpersonal (e.g., glib or su-
perficial interpersonal style), affective (e.g., low empathy, lack of remorse or guilt), and/or lifestyle (e.g., high
impulsivity, high social deviance, antisociality) traits. CU traits correspond most closely to the affective facet
of psychopathy.

www.annualreviews.org • Conduct Disorders and Empathy Development 395

  Children with conduct problems show very different emotional correlates depending on
whether their conduct problems are accompanied by elevated CU traits (i.e., associations
with emotional hyporeactivity at high levels of these traits but emotional hyperreactivity at
Limited Prosocial
Emotions (LPE): normative levels) (see, e.g., Kimonis et al. 2006b, 2017; Viding et al. 2012).
a specifier for the  Children with elevated CU traits show abnormalities in how they process punishment cues
diagnosis of Conduct (see, e.g., Gluckman et al. 2016, O’Brien & Frick 1996).
Disorder in the  Conduct problems in those with elevated CU traits are less consistently associated with
DSM-5 and
hostile and inconsistent parenting but more strongly associated (inversely) with warm and
Oppositional Defiant
Disorder and responsive parenting (see Clark & Frick 2018, Pasalich et al. 2011, Waller et al. 2015).
Conduct-Dissocial On the basis of these findings, the most recent editions of both the DSM [i.e., DSM-5 (Am.
Disorder in ICD-11
that is based on the
Psychiatr. Assoc. 2013)] and the International Classification of Diseases [ICD-11 (WHO 2018)] have
presence of elevated included CU traits in their diagnostic classification of conduct disorders with a specifier labeled
CU traits “with Limited Prosocial Emotions” (LPE).2
Thus, there is strong evidence that CU traits are important for designating a clinically and
etiologically important subtype of conduct disorders in children and adolescents. These charac-
teristics also suggest that the developmental processes that have gone awry for this group are very
different from the processes that underlie the behavior of the adolescent-onset group and the be-
havior of those with childhood-onset conduct disorders but without elevated CU traits. Further,
we have argued that these processes involve early deviations in the child’s affiliative motivations
that influence many types of emotional expression—most notably, empathic concern for others
(Dadds & Frick 2019). That is, emotional deficits experienced by children in this subgroup make
it difficult for them to learn to take the perspective of others because a child may not be motivated
to do so and may not experience the same level of aversive arousal to others’ distress (Frick et al.
2014a). Additionally, the child may not show emotional responses to parental sanctions that help
children learn to internalize societal standards for conduct. However, if parents are able to pro-
vide a warm and responsive environment, the child may be able to overcome these temperamental
risks and learn to regulate their behavior and develop perspective-taking skills. This potential in-
teraction of temperamental risk and parenting is illustrated by findings from a large sample (N =
561) of children who were adopted within a few days of birth (Hyde et al. 2016). Despite having
no contact with biological parents, biological mothers’ self-reported fearlessness was related to
children’s CU behaviors at 27 months of age. However, this link was modified by adoptive par-
ents’ behavior, such that their use of positive reinforcement reduced the association between early
fearlessness and later CU traits.
From both the definition of CU traits and the theoretical formulations for how they develop,
it is clear that a callous lack of empathy is critical to this construct. However, most theoretical
formulations have not integrated the rather extensive research on the various types of empathy or
research on how empathy typically develops with causal theories of CU traits and conduct disor-
ders. We feel not only that this integration could have important implications for enhancing our
causal theories for CU traits and conduct disorders but also that it could be critical for advanc-
ing knowledge on some of the most serious consequences of CU traits (e.g., aggression) and for
improving interventions designed to prevent or reduce these consequences.

2 In the DSM-5, criteria for the LPE specifier consist of the four indicators identified in research as being most

indicative of CU traits, two of which must have been met for the previous 12 months and must be displayed
across multiple relationships and settings. In ICD-11, the criteria also include an insensitivity to punishment
as a fifth indicator.

396 Frick • Kemp

OVERVIEW OF EMPATHY DEVELOPMENT
Empathy is defined broadly as the process by which individuals are able to recognize, understand,
and share in or react to the emotional states of others (de Waal & Preston 2017, Eisenberg et al. Affective empathy:
2014). Appropriate empathy development has long been considered vital to the acquisition of a reflexive or
self-regulation skills and, as a result, to healthy socioemotional development (Decety et al. 2016, automatic ability to
react to (e.g., via
Eisenberg et al. 2014). Further, empathy has been shown to play a positive role in social learning
mechanisms involved
and communication, prosocial behavior, and successful engagement in social-affiliative processes in physiological
across the life span (de Waal 2008, Spinrad & Eisenberg 2017). As a result, empathy is largely arousal) and/or
considered a fundamental human trait necessary for both survival and social success (de Waal experience (e.g.,
2008, de Waal & Preston 2017, Decety et al. 2016). emotional contagion)
the emotions of
another
Affective Versus Cognitive Empathy
Cognitive empathy:
There is general consensus that empathy comprises two primary components: affective empa- a higher-order, more
thy and cognitive empathy. Affective empathy refers to the emotional reaction in a person that is cognitively complex
phenomenon
elicited by the emotions of others. This emotional responsiveness includes both emotional reactiv-
including abilities to
ity (i.e., negative arousal or distress experienced in response to another’s emotions) and emotional accurately recognize,
contagion (i.e., sharing in the subjective experience of the emotion displayed by another) (de Wied identify, and share in
et al. 2010). Affective empathy is thought to represent a more evolutionarily rudimentary and au- the perspective of
tomatic and/or reflexive process (Blair 2005). It is measured by a number of methods, including another
self-reported arousal and emotional contagion (see, e.g., de Wied et al. 2010), behavioral measures
of attentional orienting and allocation (see, e.g., Ciucci et al. 2018), psychophysiological measures
of autonomic reactivity (see, e.g., de Wied et al. 2010, Hawes et al. 2009), and neural measures of
brain activity (see, e.g., Blair 2007, de Wied et al. 2010, Marsh & Blair 2008).
Alternatively, cognitive empathy refers to the ability to accurately recognize and identify
another’s emotions (i.e., emotion recognition) and to understand another’s perspective (i.e.,
perspective-taking) (Decety & Jackson 2004). As such, cognitive empathy is said to represent a
more sophisticated, intentional, and cognitively complex phenomenon (de Waal & Preston 2017).
Further, it requires a number of complex cognitive functions, such as neurocognitive skills for
accurately labeling emotional expressions, distinguishing between one’s own and others’ mental
states [e.g., Theory of Mind (ToM)], and mentalizing or perspective-taking (Decety & Jackson
2004).
Neuroimaging studies have found a distinction between affective and cognitive empathy,
such that distinct brain regions appear to be responsible for the two components. These studies
show that affective empathy is related to activity in phylogenetically (i.e., evolutionarily) older,
deeper brain structures thought to be responsible for processing emotional stimuli, including the
insula and limbic structures (e.g., amygdala, cingulate cortex) (see de Wied et al. 2010, Decety
et al. 2016, Moul et al. 2018). Conversely, cognitive empathy skills are related to activity in
phylogenetically younger, prefrontal brain areas thought to be related to higher-order processes
associated with executive function (e.g., dorsolateral and medial prefrontal cortex) as well as
regions related to sensory processing (e.g., superior temporal sulcus, temporal pole) (de Wied
et al. 2010, Moul et al. 2018). While affective and cognitive empathy appear to be differentially
related to particular brain areas, there is also evidence for their interdependence based on their
recruitment of shared neural networks (see Decety & Jackson 2004, Fan et al. 2011). For instance,
Fan et al. (2011) conducted a meta-analysis across 40 studies and reported that the left anterior
insula was consistently activated during both affective and cognitive empathy tasks. In addition,
behavioral and neuroimaging data support this interdependence as cognitive empathy paradigms
(i.e., perspective-taking and mentalizing tasks) are associated with faster response time and

www.annualreviews.org • Conduct Disorders and Empathy Development 397

 increased activation of the amygdala and temporal poles in addition to the prefrontal cortex
(Decety & Jackson 2004). Thus, this faster response time suggests that cognitive empathy
processes may be improved or facilitated by the activation of affective empathy and associated
affective brain areas.
This evidence for the interdependence between affective and cognitive empathy on a neu-
rocognitive level is supported by a developmental relationship as well. That is, the automatic
processes that define affective empathy seem to be instrumental in motivating the acquisition of
cognitive empathy skills early in typical development (Dadds et al. 2009, Frick et al. 2014a). For
example, it is theorized that when a typically developing young child experiences empathic distress
(i.e., negative arousal, negative emotional contagion) in response to seeing a friend cry, this aversive
experience motivates the child to learn to recognize others’ emotions and adopt their perspective
so that the child may avoid similar experiences in the future. Further, with the development of
cognitive empathy skills, a typically developing child becomes more adept at identifying others’
emotional states and, as such, learns to respond with more appropriate and effective prosocial
behaviors, thus engaging in successful social-affiliative interactions with others (see Boele et al.
2019).

Timing of Empathy Development

This interdependence between affective and cognitive empathy also seems to be reflected in the
timing of their onset in typically developing children. That is, the onset of affective empathy ap-
pears developmentally before cognitive empathy. For example, infants display signs of affective
empathy in the form of reflexive crying (also called contagious crying) mere hours (18–36) after
birth (Martin & Clark 1982, Sagi & Hoffman 1976), and this marker of empathic reactivity has
been shown to continue throughout the first 9 months of life (Geangu et al. 2010). As infants age
into toddlers (i.e., 12–36 months), they begin to display increasingly complex forms (e.g., facial,
gestural-postural, vocal) of emotional reactivity and empathic concern in response to others’ emo-
tions (Eisenberg et al. 2014). During toddlerhood, this empathic concern toward others appears
to promote prosocial helping behaviors to comfort others in distress. For example, Roth-Hanania
et al. (2011) reported positive associations between affective empathy at 10 months of age and
levels of prosocial behavior toward peers in distress during the second year of life. Additionally,
Knafo et al. (2008) reported positive longitudinal associations across ages 14–36 months between
displays of empathic concern and prosocial behaviors toward both mothers and strangers in dis-
tress. Further, the sophistication of these helping behaviors increases throughout the second and
third years of life as children are shown to progress from primarily physical methods of comfort-
ing (e.g., hugging) to more sophisticated, verbal methods (e.g., purposeful distraction) (Eisenberg
et al. 2014).
In addition to these reflexive affective empathy processes motivating more sophisticated
empathic concern and prosocial responsiveness, it has been proposed that affective empathy
motivates the development of cognitive empathy (Hawes & Dadds 2012, Singer 2006). Specif-
ically, the ability to understand and verbally describe others’ perspectives appears to develop
around 4 years of age and seems to become more advanced with age (Hawes & Dadds 2012). For
example, in a study by Schwenck et al. (2014) that included a sample of children aged 7–17 years,
about one-third of the variance in cognitive empathy (i.e., mentalizing and perspective-taking)
was accounted for by child age. Additionally, accurate recognition of both simple and complex
emotions, based on full facial expressions, has been shown to develop throughout childhood
and adolescence; recognition of simple emotions, such as sadness, is typically achieved by

398 Frick • Kemp

midchildhood, and an increasing ability to recognize complex emotions, like disgust, develops
from late childhood to early adolescence (Lawrence et al. 2015).

Temperament and Parenting in the Development of Empathy

Childhood temperament is often defined by individual differences in emotionality, both reactiv-
ity and regulation, that are apparent early in life and are assumed to have a constitutional basis
(Frick & Morris 2004). Given that reflexive crying is present at birth, an individual’s early empathic
responsiveness could itself be considered a dimension of temperament. However, individual dif-
ferences in this specific type of emotional reactivity are often embedded in more general patterns
of reactivity to various types of social (e.g., responses to the eyes and voices of caregivers) and
nonsocial (e.g., reactivity to shapes and objects) stimuli in infants (Dadds & Frick 2019).
One temperamental dimension that has long been included in many typologies has been la-
beled as behaviorally uninhibited (Kagan et al. 1988) or fearless (Rothbart 1981) and is defined
by a tendency to seek out novel and dangerous activities and to show less physiological arousal
to (a) unfamiliar people and circumstances, (b) punishment cues, and (c) other negative emotional
stimuli. Further, studies have shown that infants (Rothbart et al. 1994) and toddlers (Cornell &
Frick 2007) higher on fearfulness tend to be rated as more empathic by parents. Conversely, other
studies have reported that, in preschool children, lower behavioral inhibition and fearfulness pre-
dict lower levels of teacher- and parent-rated empathy later in childhood (Kimonis et al. 2006a,
Waller et al. 2019). Additionally, there is some evidence that reduced affective and motor arousal
and responsiveness to novel, sensory stimuli in infancy predict reduced empathic responsiveness
and affective empathy in toddlerhood (Young et al. 1999).
Thus, early variations in empathic arousal seem to be embedded within broader temperamental
propensities that then increase or decrease a child’s risk for problems in socioemotional develop-
ment, including problems in later, more complex forms of empathy (Dadds & Frick 2019). How-
ever, developmental research also demonstrates the importance of how these temperamental traits
in the child interact with the child’s experiences. Most notably, research shows that how a child’s
early temperament relates to their later expression of empathy can be modified by the type of
parenting they experience (Frick & Morris 2004). For example, Feldman (2007) noted the impor-
tance of parent–child synchrony (i.e., temporal matching of behavior) in empathy development,
finding that higher levels of mother–child face-to-face synchrony during the first year of life pre-
dicted higher rates of affective empathy in middle childhood and adolescence. In addition, studies
have consistently shown that parenting characterized by warmth, sensitivity, and reciprocity be-
tween parent and child is important for promoting empathy development (for reviews, see Frick
& Morris 2004, Waller et al. 2013).
There is also evidence that certain types of parenting may be particularly important for the de-
velopment of empathy in children with distinct temperamental profiles. For example, Kochanska
(1997) (see also Kochanska & Murray 2000) proposed that the parent–child relationship, especially
the degree of warmth and responsiveness between parent and child (i.e., mutually responsive ori-
entation), may be important for empathy development in fearless children. That is, children who
do not become strongly emotionally aroused by distress in others may still learn to take others’
perspectives in the context of a relationship that models empathic concern toward others (see
Kochanska 1995, 1997). Specifically, one longitudinal study by Kochanska et al. (2005) found that,
in children as young as 9 months of age, warm and responsive parenting predicted greater levels
of empathy and other moral emotions (i.e., guilt) at 45 months. In contrast, harsh parenting has
been found to exacerbate the effects of fearless temperament on empathy development (Waller
et al. 2019).

www.annualreviews.org • Conduct Disorders and Empathy Development 399

 Empathy in Broader Developmental and Psychopathological Constructs
One of the reasons that empathy has been a construct that has been the focus of a great deal
Conscience: internal of research is that empathy development, whether typical or atypical, has been found to play an
system by which important role in a number of developmental theories and causal models for important clini-
persons set standards cal constructs. In particular, research supports a role for empathy in the normal development of
and regulatory
conscience in children (Aksan & Kochanska 2005, Kochanska & Thompson 1997, Thompson
strategies for their
behavior (i.e., “learn 2012). In addition, two specific forms of psychopathology—autism spectrum disorder (ASD) and
right from wrong”), psychopathy—show distinct types of empathy deficits, which are critical for causal theories of these
which is motivated by clinical constructs. In this section, we provide a brief summary of the research linking empathy to
moral emotions, such these theories and constructs.
as empathy and guilt

Conscience. In the section above, we have made the case that empathy is an important construct
for children’s healthy socioemotional development. This contention is also supported by research
showing that empathy is a critical component to other developmental processes that are linked to
socioemotional competence and by the fact that deficient empathy has been linked to a number
of psychopathological constructs. First, empathic concern has been considered one component
of the broader construct of conscience (Frick et al. 2014a). Conscience is a construct defined by
emotional, cognitive, and relational processes by which children acquire internal standards for
conduct and the ability to regulate their own behavior (Kochanska & Thompson 1997). More
specifically, the affective components of conscience refer to the moral, prosocial, or self-conscious
emotions (e.g., guilt, anxiety, pride) experienced in response to real or imagined consequences of
one’s behavior. Additionally, cognitive components of conscience refer to higher-order cognitive
skills for behavioral self-control and self-regulation, and relational components refer to a child’s
commitment to their caregivers’ values and standards and to their openness to socialization by
caregivers (Kochanska & Thompson 1997). Finally, healthy conscience development is considered
the ultimate goal of socialization of the developing child, whereby the child can effectively function
in a social world by developing healthy relationships and learning to follow social norms and
cultural codes of conduct (Kochanska & Thompson 1997).
Kochanska and colleagues (e.g., Aksan & Kochanska 2005, Kochanska & Thompson 1997)
have conceptualized conscience as relying, at least in part, on healthy or intact empathy. That is,
the desire to change one’s behavior because of its effects on others, rather than simply because of its
effects on oneself, is dependent on empathic concern toward others. Similarly, the desire to change
behavior to avoid displeasing or disappointing socializing agents (e.g., parents, teachers, peers)
is dependent on the child’s recognition and concern about others’ emotions. This link between
empathy and conscience is not just theoretical. Aksan & Kochanska (2005) reported that levels
of affective empathy (i.e., reactivity to strangers’ distress) and moral emotions (i.e., guilt elicited
by a personally caused mishap) experienced during the second and third years of life predicted
greater engagement in rule-compatible conduct, even in the absence of adult supervision, later
in childhood. Further, there is evidence that cognitive empathy skills (e.g., ToM) in preschoolers
are associated with greater appreciation for social standards (Kochanska & Thompson 1997) and
verbalization of prosocial moral reasoning regarding fairness to others (Thompson 2012).

Autism spectrum disorder. Deficits in cognitive empathy—specifically, perspective-taking and

ToM—have been found to be related to ASD (Blair 2005, Blair & Blair 2009, Jones et al. 2010,
Lockwood et al. 2013, Schwenck et al. 2012). A number of studies have shown that children and
adults with ASD display developmentally persistent deficits in their abilities to accurately infer
and label others’ emotions and perspectives (for a review, see Smith 2009). However, persons with

400 Frick • Kemp

ASD still show emotional reactions to others’ distress ( Jones et al. 2010). Thus, though youth
with ASD may not accurately understand others’ emotions (i.e., cognitive empathy) and may not
respond in socially appropriate ways to others’ distress, they appear to show appropriate emotional
responses to the distress of others (i.e., affective empathy).

Psychopathy. Psychopathy is a personality disorder that comprises a number of interpersonal,

affective, and lifestyle (e.g., impulsive and irresponsible behavior) traits associated with chronic,
severe patterns of aggression and offending in adults (Cleckley 1976, Hare 1993). While there is
great debate over what specific dimensions are needed to define psychopathy (see Skeem et al.
2011), most definitions include an affective facet defined by CU traits (Hare & Neumann 2008).
Thus, deficient empathy seems to be an important part of the definition of psychopathy.
Further, there is empirical evidence of deficits in empathy—particularly in affective empathy—
in those with elevated psychopathic traits. Specifically, individuals with elevated psychopathic traits
have consistently shown hyporeactivity in response to fear in others, and this pattern has been
replicated using behavioral measures of reduced attentional orienting, physiological measures of
reduced autonomic reactivity, and neural measures of reduced amygdala activation (for reviews,
see Blair 2005, 2007, 2010). Importantly, research has indicated that individuals with elevated
psychopathic traits do not seem to show deficits on measures of cognitive empathy, including ToM
(Blair 2005, 2007) and emotion recognition (Igoumenou et al. 2017, Richell et al. 2003, Wilson
et al. 2011). Thus, while psychopathic individuals and individuals with ASD both tend to show
deficits in empathy, the former seem to show deficits specific to affective empathy, whereas the
latter seem to show deficits more specific to cognitive empathy.

INTEGRATING RESEARCH ON CONDUCT DISORDERS

AND EMPATHY DEVELOPMENT
As noted above, the construct of CU traits was developed to integrate research on conscience
development and psychopathy to designate a subgroup of children with conduct disorders. As a
result, like conscience and psychopathy, empathy is considered an important component in the
construct of CU traits. Recently, Waller et al. (2020) conducted a large-scale meta-analysis of 59
studies to test this theoretical view of CU traits and reported that measures of CU traits showed
moderate-to-large negative associations with measures of empathy (ρ = −0.57) as well as with
measures of guilt (ρ = −0.40) and prosociality (i.e., engaging in helpful or supportive behavior
toward others, ρ = −0.66). Thus, there is both theoretical and empirical support that empathy is
a critical, but not exclusive, component to the construct of CU traits.

Clarifying the Emotional Deficits Associated with Callous-Unemotional Traits

As noted above, one of the most consistent differences between children with conduct disorders
with and without elevated CU traits is that those without elevated CU traits show enhanced emo-
tional reactivity, whereas those with elevated CU traits show blunted emotional reactivity. This
finding has been critical for exemplifying why CU traits are important for specifying etiologi-
cally distinct subgroups of children with conduct disorders and thus for advancing causal the-
ory. That is, studying emotional processing in children with conduct disorders without separating
them by CU traits could result in conflicting findings depending on the sample composition (i.e.,
the relative ratio of those high and low in CU traits), with the two opposing patterns of emo-
tional responsiveness potentially canceling each other out (Frick 2012). This could lead to very

www.annualreviews.org • Conduct Disorders and Empathy Development 401

 misleading interpretations regarding the influence of emotional deficits on the development of
conduct disorders.
While emotional hyporeactivity is critical for theories of CU traits, it is also clear that, de-
spite its name, children with elevated CU traits are not unresponsive or even underresponsive to
all types of emotional stimuli. Specifically, Marsh & Blair (2008) conducted a meta-analysis ex-
amining associations for reduced facial affect processing and recognition in persons elevated on
CU traits or psychopathy more broadly. Across 20 studies (9 adolescent samples, 1 older ado-
lescent/young adult sample, and 10 adult samples), they reported a robust association between
CU traits/psychopathy and impairments in fear processing that could not be explained by task
difficulty. Across 17 studies, significant group differences were found between those high in CU
traits/psychopathy and control groups in the processing of fearful, sad, and surprised faces but no
differences in the processing of angry, disgusted, or happy faces (Marsh & Blair 2008).
Given that CU traits have been consistently related to deficient emotional reactivity to distress
cues, such as fear, it is not surprising that they have been consistently associated with deficits
in affective empathy (Waller et al. 2020). This would also be consistent with findings in adults
with elevated psychopathic traits, as discussed above. Further, given the findings for adults with
elevated psychopathic traits, one would predict that CU traits may not be as strongly associated
with cognitive empathy and related constructs, such as perspective-taking, emotion recognition,
and ToM. However, the meta-analysis by Waller et al. (2020) reported similar associations between
measures of CU traits and measures of affective (ρ = −0.33) and cognitive (ρ = −0.43) empathy.
One possible explanation for these findings could involve variations in how cognitive empathy
is measured. Waller et al. (2020) reported that associations with cognitive empathy were stronger
when rated by a parent or teacher than by self-report. Thus, children with elevated CU traits may
be perceived by others as poorer at taking others’ perspective and recognizing emotions, even if
they do not view themselves as deficient. Since cognitive empathy is typically measured by self-
report in research with adults, this method confound may explain the lack of association with
psychopathic traits in this age group.
Although laboratory measures of cognitive empathy could potentially clarify which perceptions
(i.e., informants versus self ) are more accurate, such findings are not consistent and depend on the
type of task used. For example, a number of studies have reported intact perspective-taking and
ToM in youth with elevated CU traits ( Jones et al. 2010, Lockwood et al. 2013, Schwenck et al.
2012), but findings from tasks assessing emotion recognition abilities are considerably less clear.
For example, facial morphing paradigms have demonstrated impairments in emotional process-
ing, particularly for fearful faces, in children with elevated CU traits (Blair et al. 2001, Fairchild
et al. 2009). However, these morphing tasks are difficult to interpret because they assess both re-
activity (i.e., speed of recognition) and recognition (i.e., accuracy of labeling emotion). As such,
these tasks may conflate a person’s reactivity to emotion, which increases attentional orienting
and shortens response times, with the ability to accurately identify emotions (see Moul et al. 2018,
Schupp et al. 2007). Studies that solely examined emotion recognition accuracy have reported
mixed results. Some studies have reported an association between CU traits and worse recogni-
tion of sadness (Aspan et al. 2014, Woodworth & Waschbusch 2008) and fear (Aspan et al. 2014,
Leist & Dadds 2009), while others have found a positive association between CU traits and fear
recognition ( Jones et al. 2009, Schwenck et al. 2014, Sharp et al. 2015, Woodworth & Waschbusch
2008). Additionally, tasks examining recognition of simple (e.g., sad, angry) versus complex (e.g.,
shame, guilt) emotions have reported CU-related deficits in recognizing complex emotions only
(Sharp et al. 2015). In summary, while affective empathy seems to be consistently associated with
CU traits, associations with cognitive empathy may vary according to the method of measurement.

402 Frick • Kemp

 It is also possible that associations between CU traits and empathy change across development.
In Waller and colleagues’ (2020) meta-analysis, the associations between CU traits and affective
empathy were not moderated by child’s age, whereas associations with cognitive empathy were
stronger in younger children. These age differences were also found in a study by Dadds et al.
(2009) that examined associations among CU traits and different types of parent-reported empa-
thy in four age groups: 3–4, 5–6, 7–9, and 9–13 years. The results indicated that CU traits in boys
were negatively associated with parent ratings of affective empathy across all age groups, whereas
CU traits were negatively related to cognitive empathy only in the two younger age groups (Dadds
et al. 2009). Further, studies that have found negative associations between CU traits and emo-
tion recognition have largely been in young children (for a review, see Blair 2005; see also Sharp
et al. 2015), while studies that have failed to find such associations have been conducted in older
children and adolescents ( Jones et al. 2009, Schwenck et al. 2014, Sharp et al. 2015, Woodworth
& Waschbusch 2008).
Thus, it is possible that deficient emotional reactivity to others’ distress (i.e., affective empathy)
leads to reduced intrinsic motivation to develop perspective-taking and accurate emotion recog-
nition skills, as suggested by developmental models. However, this does not necessarily mean that
children with elevated CU traits, who lack this emotional arousal, are unable to acquire these
cognitive empathy skills over time. Rather, it is possible that, as youth with elevated CU traits
grow older, they experience extrinsic motivation to acquire emotion recognition skills, which en-
able them to use social cues to their advantage (Dadds et al. 2009). For example, the ability to
understand others’ emotions may allow youth with elevated CU traits to be more effective at in-
terpersonal manipulation and social dominance, which have been shown to be important social
goals for youth with elevated CU traits (Frick et al. 2014b). Thus, the association between CU
traits and cognitive empathy may change across development.
Another potential explanation for these inconsistent associations between cognitive empathy
and CU traits relates to the possible presence of two variants of CU traits that differ in their
etiology. That is, similar to adults with psychopathy, youth with elevated CU traits can be separated
into those who show low or normative levels of anxiety (i.e., the primary variant) and those who
show high levels of anxiety (i.e., secondary variant) (Kimonis et al. 2012). Further, these variants
differ on emotional reactivity: The primary variant is uniquely associated with lower levels of
reactivity to others’ distress, and the secondary variant is uniquely associated with higher rates of
abuse and exposure to violence (Dadds et al. 2018; Kahn et al. 2013, 2017; Kimonis et al. 2012).
Thus, the primary variant has been hypothesized to develop from a temperament characterized
by low levels of emotional reactivity, which interferes with the development of empathy and guilt,
whereas the secondary variant may be the result of an acquired deficit due to the experience of
trauma (Kahn et al. 2013). That is, in this latter group, elevated CU traits are proposed to result
from an acquired cognitive bias for perceived threats to self, as a function of past trauma, which
can lead to problems recognizing others’ emotions due to a tendency to overinterpret all emotions
as threatening (Kahn et al. 2013).
As a result, it is possible that the different types of empathy are differentially related to the two
variants of CU traits, and this could contribute to the conflicting findings from studies that have
not considered differences between variants. In one of the few tests of this possibility, Kahn et al.
(2017) reported that, in a sample of detained adolescents, CU traits were negatively associated with
self-reported affective empathy regardless of anxiety level, whereas negative associations with self-
reported cognitive empathy were found only at high levels of anxiety. In addition, CU traits were
associated with better performance on a ToM task and with better recognition of fearful faces
at low levels of anxiety (Kahn et al. 2017). While these findings are promising, two more recent
studies did not provide strong support for these hypothesized differences between variants. Dadds

www.annualreviews.org • Conduct Disorders and Empathy Development 403

 et al. (2018) used both presence of anxiety and maltreatment history to form variants of CU traits
in youth between the ages of 3 and 16 and reported that youth with the primary variant performed
worse on a behavioral task assessing emotion recognition. Kyranides et al. (2020) reported that,
in a sample of older adolescents and young adults (mean age = 19.95, SD = 1.01), both primary
and secondary CU variants performed poorly on an emotion recognition task, but the low-anxiety
primary variant engaged in fewer fixations to facial stimuli expressing pain and fear. Thus, whereas
both CU variants showed emotion recognition deficits, they differed in how they engaged with or
attended to (i.e., visual gaze and fixation) faces depicting pain and fear (Kyranides et al. 2020).
In conclusion, empathy deficits are considered a core part of the construct of CU traits, and
therefore they need to be considered in causal theories of children and adolescents with con-
duct disorders. Specifically, theories should consider that deficits in affective empathy seem to be
consistently found in children with conduct disorders and elevated CU traits, whereas deficits in
cognitive empathy are less consistently reported in this group. Future research needs to clarify
the reasons for this inconsistent association with cognitive empathy, including whether it is due
to differences in how it is measured (e.g., self- versus other-report, ToM versus more complex
perspective-taking) and whether the association changes across development. Research should
also test differences across variants of CU traits defined by elevated anxiety, although studies to
date comparing the two CU variants on measures of empathy have reported inconsistent results.

Explaining the Association Between Callous-Unemotional Traits and Aggression

As noted above, developmental research on empathy has largely focused on the importance of em-
pathy for motivating prosocial behavior. However, empathy has also been considered an important
developmental process for inhibiting aggressive behavior. Specifically, being able to recognize pain
and distress in others and being disturbed by such emotional reactions is thought to be critical for a
child learning to inhibit behaviors that would cause those emotions in others (Blair & Blair 2009).
Thus, empathy deficits could be critical for explaining why children and adolescents with conduct
disorders and elevated CU traits are more likely to show a severe pattern of aggressive and violent
behavior (Frick et al. 2014b).
While this theoretical link between empathy and aggression is widely cited, the empirical sup-
port for it has been relatively weak. For example, an early meta-analysis by Miller & Eisenberg
(1988) reviewed 30 studies and reported an average correlation of only r = −0.18 between empa-
thy and aggression across the life span. In a more recent meta-analysis of only studies using adult
samples, Vachon et al. (2014) analyzed 106 effect sizes and reported an average correlation of r =
−0.11. There are several possible explanations for this relatively modest association. For example,
though empathy alone accounts for only modest variance in measures of aggression, it could be
an important part of broader constructs related to prosociality, such as the personality dimension
of agreeableness or within definitions of CU traits and psychopathy (Vachon et al. 2014). Alterna-
tively, it could be that empathy is more highly related to developing aggression in younger samples
(i.e., by motivating children to avoid behaviors that harm others) but that, later in development,
the functional benefits that may result from aggression (e.g., obtaining something tangible by
force, gaining dominance in social settings) become more important ( Jolliffe & Farrington 2004).
However, we propose another interpretation of these findings that could be critical for un-
derstanding the developmental pathways to conduct disorders: that these modest correlations be-
tween empathy and aggression may have been due to a failure to consider different forms of ag-
gression. Vachon et al. (2014) did consider possible differences in associations between empathy
and several types of aggression in their meta-analysis and found consistent, modest correlations
with empathy for measures of verbal aggression (r = −0.20), physical aggression (r = −0.12), and

404 Frick • Kemp

sexual aggression (r = −0.09). However, they did not consider the distinction between reactive
aggression, which is an impulsive response to perceived provocation, and proactive or instrumen-
tal aggression, which is a planned response to obtain some instrumental gain (Little et al. 2003,
Poulin & Boivin 2000).
This distinction could be important for a number of reasons. First, reactive aggression and
proactive aggression appear to have different emotional correlates, with reactive aggression more
strongly associated with poorly regulated emotional responses to provocation (Muñoz et al. 2008).
Second, reactive and proactive aggression are highly correlated; estimates across samples average
r = 0.70 (Little et al. 2003, Poulin & Boivin 2000). However, this overlap appears to be asymmet-
rical: Many children show purely reactive aggression, a smaller number show both reactive and
proactive aggression, and very few children show only proactive aggression (Marsee et al. 2014).
Third, the emotional correlates to reactive aggression, particularly the dysregulated emotional re-
activity to provocation, appear limited to those who show only reactive aggression (Muñoz et al.
2008, Hubbard et al. 2002). Thus, the emotional correlates to reactive aggression may differ de-
pending on the co-occurrence of proactive aggression. Fourth, reactive aggressive behaviors tend
to be displayed more commonly (i.e., by more people) and more frequently (Marsee et al. 2014).
As a result, the variance in most aggression measures is likely to be largely due to variation in
reactive aggressive behaviors and not proactive aggression.
These findings could explain why correlations between empathy and aggression have not been
strong in past research while empathy deficits could still be important for explaining some of the
significant impairments in children with conduct disorders and elevated CU traits. That is, in
school-based samples (Crapanzano et al. 2010), high-risk samples (Frick et al. 2003a, Marsee et al.
2014), and juvenile justice samples (Kruh et al. 2005, Lawing et al. 2010, Marsee et al. 2014), CU
traits are elevated, relative to nonaggressive children and adolescents, only in those high in both
reactive and proactive aggression. Importantly, these children with elevated CU traits not only
show both forms of aggression but also tend to show the highest rates of aggression overall (Frick
et al. 2003a) as well as aggression that results in more serious harm to others (Kruh et al. 2005,
Lawing et al. 2010). Conversely, children with conduct disorders without elevated CU traits, who
do not show empathy deficits, tend to show elevated rates of reactive aggression only (Frick et al.
2003a, Kruh et al. 2005). Although not explicitly tested, it is thus possible that deficits in empathy
are related only to proactive forms of aggression that are often displayed with reactive aggression,
not to reactive aggression alone. Thus, overall measures of aggression, which are highly weighted
toward reactive aggression, are likely to show only modest associations with empathy.
In conclusion, despite past research showing modest associations between empathy and broad
measures of aggression, deficits in empathy could still be important for explaining why children
with conduct disorders and elevated CU traits show a severe pattern of aggression and violence
that results in significant harm to others. Future research needs to determine whether it is empathy
deficits or other components to CU traits that play an important role in the aggressive behavior
displayed by these children with conduct disorders. However, it is important that this research take
into account associations between reactive and proactive aggression, such as by controlling for the
other form of aggression when testing its association with empathy or by using person-centered
approaches that take into account how the two forms of aggression are expressed in children
and adolescents (i.e., a large number of children showing reactive aggression, a smaller number
showing both forms of aggression, and very few children showing only proactive aggression).
Finally, given that empathy deficits may play a role in the aggressive behavior of children with
conduct disorders and elevated CU traits, it is possible that interventions targeting deficits in
empathy could be important for reducing the aggressive behavior in these children (Frick 2012).

www.annualreviews.org • Conduct Disorders and Empathy Development 405

 IMPLICATIONS FOR TREATMENT
Research on the treatment of conduct disorders suggests three overarching principles:

1. Early intervention is more effective than treatment later in development;

2. intervention needs to be comprehensive, targeting multiple risk factors that lead a child to
act in a way that violates the rights of others and/or major age-appropriate norms; and
3. intervention needs to be tailored to the unique needs of children in the various develop-
mental pathways to conduct disorders (Frick 2012).

We feel that integrating research on empathy development could be beneficial for advancing each
of these components to treatment.
In terms of early intervention, most current research has focused on identifying conduct prob-
lems when they first emerge and intervening in their trajectory as early as possible (Frick 2012).
However, this approach still necessitates that the conduct problems have already become impair-
ing or at least evident to others. By viewing CU traits as partly determined by deficient empathy
development, interventions may begin even earlier, when signs of problematic empathy develop-
ment are emerging, with the goal of preventing conduct problems from developing at all. To make
this feasible, research has identified a number of signs of atypical or deficient empathy develop-
ment that have been empirically linked to later CU traits, including lower preference for faces
(i.e., as evidenced by less facial tracking with direct gaze) at 5 weeks of age (Bedford et al. 2014),
less observed eye contact during mother–child interactions at 6 months (Bedford et al. 2017), less
physical and verbal affection displayed toward parents at 18 months (Waller et al. 2016), less so-
cial imitation at 2 years (Wagner et al. 2020), and fewer displays of social engagement at 3 years
(Waller et al. 2019).
Research on empathy development could help to guide intervention for young children show-
ing these early risk indicators. That is, intervention to prevent the development of conduct dis-
orders can draw on research on the parenting practices that have been shown to predict higher
levels of empathy in young children, including the following:

 increased parental warmth and sensitivity/responsivity to the child’s emotional cues and
needs (i.e., providing a model for emotional responsiveness through enhanced parent–child
synchrony);
 having emotion socialization encouraged by parents (e.g., by encouraging open communi-
cation about emotions to improve emotion knowledge); and
 encouragement and reinforcement of child engagement in empathic responding and proso-
cial behavior (e.g., parents’ positive reinforcement of child’s prosocial behavior) (Spinrad &
Gal 2018).

Though relatively few studies have empirically tested changes in children’s empathy as an out-
come of such parenting interventions, Havighurst and colleagues have integrated these parenting
practices as part of their “Tuning into Kids” program with positive results. Specifically, Havighurst
et al. (2010) provided a six-session intervention in a community sample of 216 parents of children
aged 4–5 years and showed increases in parents’ emotion socialization skills (e.g., parental warmth
and responsiveness) that were associated with increases in children’s emotion knowledge (i.e., emo-
tion recognition and perspective-taking; Cohen d = 1.00) and reductions in informant-reported
conduct problems (Cohen d = 0.23 and 0.57 for teacher report and parent report, respectively)
at 6-month follow-up. While these results are promising, more data are needed on whether initi-
ating such interventions prior to the onset of serious conduct problems can prevent the onset of
later conduct disorders.

406 Frick • Kemp

 Once conduct disorders develop, research on empathy development, particularly on optimal
parenting to promote empathy development, can be applied to enhance existing interventions. For
example, a meta-analysis of 78 studies conducted by Piquero et al. (2016) reported that behavioral
parenting interventions (BPIs) were highly effective (d = 0.37) in reducing behavior problems in
children both at home and at school. Unfortunately, these interventions have proven less effective
for children with elevated CU traits (Frick et al. 2014b, Wilkinson et al. 2016). Like treatment
research in general, this research does not indicate that these interventions are ineffective for
children with elevated CU traits. Instead, treatment outcome research consistently indicates that
children with elevated CU traits often start BPI treatment with more severe behavior problems
and, while showing reductions in conduct problems after treatment, still typically show behav-
ior problems in the clinically significant range (for a review, see Wilkinson et al. 2016). Thus,
a potential way to treat conduct disorders early in development is to make these interventions
more effective by enhancing them on the basis of research on empathy development and on the
characteristics of CU traits themselves.
One example of this approach was taken by Kimonis et al. (2019), who worked to enhance
Parent–Child Interaction Therapy (PCIT) (Hembree-Kigin & McNeil 1995), a BPI that has
proven to be highly efficacious for treating conduct disorders in young children (Thomas &
Zimmer-Gembeck 2007, Thomas et al. 2017, Ward et al. 2016). Like other interventions, the
traditional version of PCIT has been less effective for treating children with elevated CU traits
(Kimonis et al. 2014). However, PCIT includes a number of characteristics that make it a com-
pelling platform for adding enhancements to more effectively intervene with children high in CU
traits. First, its emphasis on strengthening the parent–child relationship via positive parenting
strategies is consistent with the importance of the parent–child relationship for empathy devel-
opment and the inverse association between parental warmth and conduct problems in children
with elevated CU traits. Second, research supports the feasibility and preliminary efficacy of PCIT
adaptations that integrate targeted emotion skills training delivered by parents to improve emo-
tional outcomes for other childhood disorders (e.g., pediatric depression) (Luby et al. 2012). Third,
meta-analytic findings suggest that treatment effects were larger and attrition rates were lower for
PCIT relative to other BPIs for treating conduct disorders (Thomas & Zimmer-Gembeck 2007).
To make PCIT more effective for children with elevated CU traits, Kimonis et al. (2019) de-
veloped PCIT-CU, a variant of PCIT with three primary modifications:

 coaching parents to engage in warm and emotionally responsive parenting;

 shifting emphasis from punishment to reward to achieve effective discipline by supplement-
ing punishment (e.g., time-out) with intensive and individualized reward-based techniques
(e.g., token economy); and
 delivering an adjunctive module called Coaching and Rewarding Emotional Skills (CARES)
to target empathy and other emotional deficits (for the specific skills taught, see the sidebar
titled Treatment for Young Children with Conduct Disorders).

Kimonis et al. (2019) reported on an open trial of their PCIT-CU intervention in 23 children
(aged 3–6 years) with conduct disorders and elevated CU traits who were referred to a university-
based mental health clinic. The authors reported a high retention rate (74%) and high levels of
parent-reported satisfaction with the program. Further, the intervention produced decreases in
child conduct problems and CU traits and increases in empathy, with substantial effect sizes (d =
0.7–2.0) that were maintained at 3-month follow-up (Kimonis et al. 2019).
In conclusion, research on empathy development could aid in the prevention of conduct
problems and in the treatment of young children with conduct disorders and elevated CU traits,
a group that has heretofore been less responsive than other children with conduct disorders to

www.annualreviews.org • Conduct Disorders and Empathy Development 407

TREATMENT FOR YOUNG CHILDREN WITH CONDUCT DISORDERS
Kimonis et al. (2019) modified Parent–Child Interaction Therapy (PCIT; Hembree-Kigin & McNeil 1995) in
several ways to be more effective for children with elevated CU traits. One of the key modifications included in
this intervention labeled PCIT-CU was a 6-session adjunctive module called Coaching and Rewarding Emotional
Skills (CARES) to enhance empathy (Fleming & Kimonis 2018). It specifically targeted the following skills:
 enhancing attention to critical facial cues (i.e., microexpressions) that signal distress in others to improve
emotion recognition in the child;
 improving emotional understanding by linking emotional expressions in others to the situation in which

they occur and identifying situations that trigger anger and frustration in the child;
 teaching and positively reinforcing prosocial and empathic behavior in the child, with parental modeling,
role-play, and social stories; and
 increasing frustration tolerance in the child through modeling, role-play, and reinforcing use of learned
cognitive-behavioral strategies to decrease the incidence of aggressive behavior.

traditional mental health interventions. Specifically, such research can provide markers for early
problems in empathy development that can be targeted for intervention before serious conduct
problems emerge. Further, research on the specific aspects of parenting that are related to empathy
development can be used to guide these early preventive interventions. In addition, this research
on factors that promote empathy development, combined with other research on the unique
characteristics of children with elevated CU traits, can aid in modifying existing treatments for
conduct disorders to make them more effective for this clinically important subgroup of children.

SUMMARY POINTS
1. There are multiple developmental pathways to conduct disorders, which differ not only
in underlying etiological mechanisms but also in severity, chronicity, and response to
treatment.
2. One marker for a distinct pathway with both etiological and clinical importance is the
presence of elevated callous-unemotional (CU) traits, which has now been integrated
into major diagnostic systems for conduct disorders.
3. A key component to CU traits is deficient empathy; thus, research on the typical de-
velopment of empathy could help to advance research on how it may go awry in chil-
dren with elevated CU traits, explain some of the major areas of impairment in children
with elevated CU traits, and advance early interventions for this group of children who
heretofore have not responded as well to traditional mental health treatments.
4. Empathy involves an affective component (e.g., emotional reactivity) that is present from
birth and that motivates later acquisition of more complex cognitive empathy (e.g., emo-
tion recognition, perspective-taking).
5. CU traits have been consistently related to deficits in affective empathy across ages and
methods of assessment, but findings on cognitive empathy have been considerably less
clear; these inconsistencies may be due to differing ways in which cognitive empathy is
assessed and/or to changes in these deficits across development.

408 Frick • Kemp

 6. Empathy deficits may help to explain why persons with elevated CU traits show elevated
levels of proactive and instrumental aggression that result in significant harm to others.
7. Research on empathy development and, in particular, research on parenting practices
that can enhance empathy development (e.g., warm and responsive parenting) can be
used to develop interventions that promote empathy development prior to the onset of
conduct disorders and also can be used to enhance treatments for young children with
conduct disorders and elevated CU traits.

FUTURE ISSUES
1. Clarify how pervasive the emotional deficits associated with CU traits are, which includes
studying deficits in affective and cognitive empathy across development.
2. Clarify how temperament and parenting interact in the development of empathy to help
guide interventions for children showing early signs of empathy deficits.
3. Clarify the role that empathy deficits play in the development of severe patterns of ag-
gression, while controlling for the correlation between reactive and proactive forms of
aggression.
4. Test whether interventions that focus on enhancing empathy development in young chil-
dren prevent later conduct disorders.
5. Rigorously test, with randomized controlled trials, interventions for children with con-
duct disorders and elevated CU traits that are based on research on parenting practices
that promote empathy development and other characteristics associated with CU traits
to enhance the effectiveness of traditional treatments for conduct disorders.

DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.

LITERATURE CITED
Achenbach TM, Edelbrock CS. 1978. The classification of child psychopathology: a review and analysis of
empirical efforts. Psychol. Bull. 85:1275–301
Aksan N, Kochanska G. 2005. Conscience in childhood: old questions, new answers. Dev. Psychol. 41(3):506–16
Am. Psychiatr. Assoc. 1980. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Publ. 3rd ed. [DSM-III]
Am. Psychiatr. Assoc. 1987. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Publ. 3rd ed., rev.
Am. Psychiatr. Assoc. 2013. Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: Am. Psychiatr.
Publ. 5th ed.
Aspan N, Bozsik C, Gadoros J, Nagy P, Inantsy-Pap J, et al. 2014. Emotion recognition pattern in adolescent
boys with attention-deficit/hyperactivity disorder. BioMed Res. Int. 2014:761340
Bedford R, Pickles A, Sharp H, Wright N, Hill J. 2014. Reduced face preference in infancy: a developmental
precursor to callous-unemotional traits? Biol. Psychiatry 78(2):144–50

www.annualreviews.org • Conduct Disorders and Empathy Development 409

 Bedford R, Wagner NJ, Rehder PD, Propper C, Willoughby MT, Mills-Koonce RW. 2017. The role of in-
fants’ mother-directed gaze, maternal sensitivity, and emotion recognition in childhood callous unemo-
tional behaviours. Eur. Child Adolesc. Psychiatry 26(8):947–56
Blair RJR. 2005. Responding to the emotions of others: dissociating forms of empathy through the study of
typical and psychiatric populations. Conscious. Cogn. 14(4):698–718
Blair RJR. 2007. Empathic dysfunction in psychopathic individuals. In Empathy in Mental Illness, ed. TF Farrow,
PW Woodruff, pp. 3–16. Cambridge, UK: Cambridge Univ. Press
Blair RJR. 2010. Neuroimaging of psychopathy and antisocial behavior: a targeted review. Curr. Psychiatry Rep.
12(1):76–82
Blair RJR, Blair KS. 2009. Empathy, morality, and social convention: evidence from the study of psychopathy
and other psychiatric disorders. In The Social Neuroscience of Empathy, ed. J Decety, W Ickes, pp. 139–52.
Cambridge, MA: MIT Press
Blair RJR, Colledge E, Murray L, Mitchell DGV. 2001. A selective impairment in the processing of sad and
fearful expressions in children with psychopathic tendencies. J. Abnorm. Child Psychol. 29(6):491–98
Blair RJR, Leibenluft E, Pine DS. 2014. Conduct disorder and callous-unemotional traits in youth. N. Eng. J.
Med. 371(23):2207–16
Boele S, Van der Graaff J, De Wied M, Van der Valk IE, Crocetti E, Branje S. 2019. Linking parent-child
and peer relationship quality to empathy in adolescence: a multilevel meta-analysis. J. Youth Adolesc.
48(6):1033–55
Brezina T, Piquero AR. 2007. Moral beliefs, isolation from peers, and abstention from delinquency. Deviant
Behav. 28(5):433–65
Burt SA, Hyde LW, Frick PJ, Jaffee SR, Shaw DS, Tremblay R. 2018. Commentary: childhood conduct prob-
lems are a public health crisis and require resources: a commentary on Rivenbark et al. J. Child Psychol.
Psychiatry 59(6):711–13
Burt SA, Rescorla LA, Achenbach TM, Ivanova MY, Almqvist F, et al. 2015. The association between ag-
gressive and non-aggressive antisocial problems as measured with the Achenbach System of Empirically
Based Assessment: a study of 27,861 parent-adolescent dyads from 25 societies. Personal. Ind. Diff. 85:86–
92
Canino G, Polanczyk G, Bauermeister JJ, Rhode LA, Frick PJ. 2010. Does the prevalence of conduct disorder
and oppositional defiant disorder vary across cultures? J. Soc. Psychiatr. Epidemiol. 45:695–704
Ciucci E, Kimonis E, Frick PJ, Righi S, Baroncelli A, et al. 2018. Attentional orienting to emotional faces
moderates the association between callous-unemotional traits and peer-nominated aggression in young
adolescent school children. J. Abnorm. Child Psychol. 46(5):1011–19
Clark JE, Frick PJ. 2018. Positive parenting and callous-unemotional traits: their association with school be-
havior problems in young children. J. Clin. Child Adolesc. Psychol. 47(Suppl. 1):S242–54
Cleckley H. 1976. The Mask of Sanity. St. Louis, MO: CV Mosby Co. 5th ed.
Cornell AH, Frick PJ. 2007. The moderating effects of parenting styles in the association between behavioral
inhibition and parent-reported guilt and empathy in preschool children. J. Clin. Child Adolesc. Psychol.
36(3):305–18
Crapanzano AM, Frick PJ, Terranova AM. 2010. Patterns of physical and relational aggression in a school-
based sample of boys and girls. J. Abnorm. Child Psychol. 38:433–45
Dadds MR, Frick PJ. 2019. Toward a transdiagnostic model of common and unique processes leading to
major disorders of childhood: the REAL model of attention, responsiveness, and learning. Behav. Res.
Ther. 119:103410
Dadds MR, Hawes DJ, Frost AD, Vassallo S, Bunn P, et al. 2009. Learning to ‘talk the talk’: the relationship
of psychopathic traits to deficits in empathy across childhood. J. Child Psychol. Psychiatry 50(5):599–606
Dadds MR, Kimonis ER, Schollar-Root O, Moul C, Hawes DJ. 2018. Are impairments in emotion recognition
a core feature of callous-unemotional traits? Testing the primary versus secondary variants model in
children. Dev. Psychopathol. 30(1):67–77
Dandreaux DM, Frick PJ. 2009. Developmental pathways to conduct problems: a further test of the childhood
and adolescent-onset distinction. J. Abnorm. Child Psychol. 37:375–85
de Waal FBM. 2008. Putting the altruism back into altruism: the evolution of empathy. Annu. Rev. Psychol.
59:279–300

410 Frick • Kemp

de Waal FBM, Preston SD. 2017. Mammalian empathy: behavioural manifestations and neural basis. Nat. Rev.
Neurosci. 18(8):498–509
de Wied M, Gispen-de Wied C, van Boxtel A. 2010. Empathy dysfunction in children and adolescents with
disruptive behavior disorders. Eur. J. Pharmacol. 626(1):97–103
Decety J, Bartal IBA, Uzefovsky F, Knafo-Noam A. 2016. Empathy as a driver of prosocial behaviour: highly
conserved neurobehavioural mechanisms across species. Philos. Trans. R. Soc. B 371(1686):20150077
Decety J, Jackson PL. 2004. The functional architecture of human empathy. Behav. Cogn. Neurosci. Rev. 3(2):71–
100
Eisenberg N, Spinrad TL, Morris A. 2014. Empathy-related responding in children. In Handbook of Moral
Development, ed. M Killen, JG Smetana, pp. 184–207. London/New York: Psychol. Press
Fairchild G, Van Goozen SHM, Calder AJ, Goodyer IM. 2013. Research review: evaluating and reformulating
the developmental taxonomic theory of antisocial behaviour. J. Child Psychol. Psychiatry 54(9):924–40
Fairchild G, Van Goozen SHM, Calder AJ, Stollery SJ, Goodyer IM. 2009. Deficits in facial expression
recognition in male adolescents with early-onset or adolescence-onset conduct disorder. J. Child Psychol.
Psychiatry 50(5):627–36
Fan Y, Duncan NW, de Greck M, Northoff G. 2011. Is there a core neural network in empathy? An fMRI
based quantitative meta-analysis. Neurosci. Biobehav. Rev. 35(3):903–11
Feldman R. 2007. Mother-infant synchrony and the development of moral orientation in childhood and ado-
lescence: direct and indirect mechanisms of developmental continuity. Am. J. Orthopsychiatry 77(4):582–
97
Fleming GE, Kimonis ER. 2018. PCIT for children with callous-unemotional traits. In Handbook of Parent-
Child Interaction Therapy, ed. LN Niec, pp. 19–34. New York: Springer
Foster EM, Jones DE (Conduct Probl. Prev. Res. Group). 2005. The high costs of aggression: public expen-
ditures resulting from conduct disorder. Am. J. Public Health 95(10):1767–72
Frick PJ. 2012. Developmental pathways to conduct disorder: implications for future directions in research,
assessment, and treatment. J. Clin. Child Adolesc. Psychol. 41(3):378–89
Frick PJ, Cornell AH, Barry CT, Bodin SD, Dane HE. 2003a. Callous-unemotional traits and conduct prob-
lems in the prediction of conduct problem severity, aggression, and self-report of delinquency. J. Abnorm.
Child Psychol. 31(4):457–70
Frick PJ, Cornell AH, Bodin SD, Dane HE, Barry CT, Loney BR. 2003b. Callous-unemotional traits and
developmental pathways to severe conduct problems. Dev. Psychol. 39(2):246–60
Frick PJ, Lahey BB, Loeber R, Tannenbaum L, Van Horn Y, et al. 1993. Oppositional defiant disorder and
conduct disorder: a meta-analytic review of factor analyses and cross-validation in a clinic sample. Clin.
Psychol. Rev. 13(4):319–40
Frick PJ, Matlasz TM. 2018. Clinical classifications of aggression in childhood and adolescence. In Handbook
of Child and Adolescent Aggression, ed. T Malti, KH Rubin, pp. 20–40. London/New York: Guilford
Frick PJ, Morris AS. 2004. Temperament and developmental pathways to severe conduct problems. J. Clin.
Child Adolesc. Psychol. 33(1):54–68
Frick PJ, Nigg JT. 2012. Current issues in the diagnosis of attention deficit hyperactivity disorder, oppositional
defiant disorder, and conduct disorder. Annu. Rev. Clin. Psychol. 8:77–107
Frick PJ, Ray JV. 2015. Evaluating callous-unemotional traits as a personality construct. J. Personal. 83(6):710–
22
Frick PJ, Ray JV, Thornton LC, Kahn RE. 2014a. Annual research review: a developmental psychopathology
approach to understanding callous-unemotional traits in children and adolescents with serious conduct
problems. J. Child Psychol. Psychiatry 55(6):532–48
Frick PJ, Ray JV, Thornton LC, Kahn RE. 2014b. Can callous-unemotional traits enhance the understanding,
diagnosis, and treatment of serious conduct problems in children and adolescents? A comprehensive
review. Psychol. Bull. 140(1):1–57
Frick PJ, Viding E. 2009. Antisocial behavior from a developmental psychopathology perspective. Dev.
Psychopathol. 21(4):1111–31
Geangu E, Benga O, Stahl D, Striano T. 2010. Contagious crying beyond the first days of life. Infant Behav.
Dev. 33(3):279–88

www.annualreviews.org • Conduct Disorders and Empathy Development 411

 Gluckman NS, Hawes DJ, Russell AMT. 2016. Are callous-unemotional traits associated with conflict adap-
tation in childhood? Child Psychiatry Hum. Dev. 47:583–92
Hare RD. 1993. Without Conscience: The Disturbing World of the Psychopaths Among Us. New York: Pocket Books
Hare RD, Neumann CS. 2008. Psychopathy as a clinical and empirical construct. Annu. Rev. Clin. Psychol.
4:217–46
Havighurst SS, Wilson KR, Harley AE, Prior MR, Kehoe C. 2010. Tuning in to kids: improving emotion
socialization practices in parents of preschool children—findings from a community trial. J. Child Psychol.
Psychiatry 51(12):1342–50
Hawes DJ, Brennan J, Dadds MR. 2009. Cortisol, callous-unemotional traits, and pathways to antisocial be-
havior. Curr. Opin. Psychiatry 22(4):357–62
Hawes DJ, Dadds MR. 2005. The treatment of conduct problems in children with callous-unemotional traits.
J. Consult. Clin. Psychol. 73(4):737–41
Hawes DJ, Dadds MR. 2012. Revisiting the role of empathy in childhood pathways to antisocial behavior. In
Emotions, Imagination, and Moral Reasoning, ed. R Langdon, C Mackenzie, pp. 45–70. London/New York:
Psychol. Press
Hembree-Kigin TL, McNeil CB. 1995. Parent–Child Interaction Therapy. New York: Springer
Hubbard JA, Smithmyer CM, Ramsden SR, Parker EH, Flanagan KD, et al. 2002. Observational, physiolog-
ical, and self-report measures of children’s anger: relations to reactive versus proactive aggression. Child
Dev. 73(4):1101–18
Hyde LW, Waller R, Trentacosta CJ, Shaw DS, Neiderhiser JM, et al. 2016. Heritable and nonheritable path-
ways to early callous-unemotional behaviors. Am. J. Psychiatry 173(9):903–10
Igoumenou A, Harmer CJ, Yang M, Coid JW, Rogers RD. 2017. Faces and facets: the variability of emotion
recognition in psychopathy reflects its affective and antisocial features. J. Abnorm. Psychol. 126(8):1066–76
Jolliffe D, Farrington DP. 2004. Empathy and offending: a systematic review and meta-analysis. Aggress. Violent
Behav. 9(5):441–76
Jones AP, Happé FGE, Gilbert F, Burnett S, Viding E. 2010. Feeling, caring, knowing: different types of
empathy deficit in boys with psychopathic tendencies and autism spectrum disorder. J. Child Psychol.
Psychiatry 51(11):1188–97
Jones AP, Laurens KR, Herba CM, Barker GJ, Viding E. 2009. Amygdala hypoactivity to fearful faces in boys
with conduct problems and callous-unemotional traits. Am. J. Psychiatry 166(1):95–102
Kagan J, Reznick JS, Snidman N, Gibbons J, Johnson MO. 1988. Childhood derivatives of inhibition and lack
of inhibition to the unfamiliar. Child Dev. 59(6):1580–89
Kahn RE, Frick PJ, Golmaryami FN, Marsee MA. 2017. The moderating role of anxiety in the associations of
callous-unemotional traits with self-report and laboratory measures of affective and cognitive empathy.
J. Abnorm. Child Psychol. 45(3):583–96
Kahn RE, Frick PJ, Youngstrom EA, Kogos Youngstrom J, Feeny NC, Findling RL. 2013. Distinguishing pri-
mary and secondary variants of callous-unemotional traits among adolescents in a clinic-referred sample.
Psychol. Assess. 25(3):966–78
Keenan K. 2012. Mind the gap: assessing impairment among children affected by proposed revisions to the
diagnostic criteria for oppositional defiant disorders. J. Abnorm. Psychol. 121(2):352–59
Kimonis ER, Bagner DM, Linares D, Blake CA, Rodriguez G. 2014. Parent training outcomes among young
children with callous-unemotional conduct problems with or at risk for developmental delay. J. Child
Fam. Stud. 23:437–48
Kimonis ER, Fanti KA, Anastassiou-Hadjicharalambous X, Mertan B, Goulter N, Katsimicha E. 2016. Can
callous-unemotional traits be reliably measured in preschoolers? J. Abnorm. Child Psychol. 44:625–38
Kimonis ER, Fanti KA, Goulter N, Hall J. 2017. Affective startle potentiation differentiates primary and sec-
ondary variants of juvenile psychopathy. Dev. Psychopathol. 29:1149–60
Kimonis ER, Fleming G, Briggs N, Brouwer-French L, Frick PJ, et al. 2019. Parent-child interaction therapy
adapted for preschoolers with callous-unemotional traits: an open trial pilot study. J. Clin. Child Adolesc.
Psychol. 48(Suppl. 1):S347–61
Kimonis ER, Frick PJ, Boris NW, Smyke AT, Cornell AH, et al. 2006a. Callous-unemotional features, be-
havioral inhibition, and parenting: independent predictors of aggression in a high-risk preschool sample.
J. Child Fam. Stud. 15(6):745–56

412 Frick • Kemp

Kimonis ER, Frick PJ, Cauffman E, Goldweber A, Skeem J. 2012. Primary and secondary variants of juvenile
psychopathy differ in emotional processing. Dev. Psychopathol. 24(3):1091–103
Kimonis ER, Frick PJ, Fazekas H, Loney BR. 2006b. Psychopathy, aggression, and the processing of emotional
stimuli in non-referred girls and boys. Behav. Sci. Law 24:21–37
Knafo A, Zahn-Waxler C, Van Hulle C, Robinson JL, Rhee SH. 2008. The developmental origins of a dispo-
sition toward empathy: genetic and environmental contributions. Emotion 8(6):737–52
Kochanska G. 1995. Children’s temperament, mothers’ discipline, and security of attachment: multiple path-
ways to emerging internalization. Child Dev. 66(3):597–615
Kochanska G. 1997. Multiple pathways to conscience for children with different temperaments: from toddler-
hood to age 5. Dev. Psychol. 33(2):228–40
Kochanska G, Forman DR, Aksan N, Dunbar SB. 2005. Pathways to conscience: early mother-child mutually
responsive orientation and children’s moral emotion, conduct, and cognition. J. Child Psychol. Psychiatry
46(1):19–34
Kochanska G, Murray KT. 2000. Mother-child mutually responsive orientation and conscience development:
from toddler to early school age. Child Dev. 71(2):417–31
Kochanska G, Thompson RA. 1997. The emergence and development of conscience in toddlerhood and early
childhood. In Parenting and Children’s Internalization of Values: A Handbook of Contemporary Theory, ed.
JE Grusec, L Kuczynski, pp. 53–77. Hoboken, NJ: Wiley
Kruh IP, Frick PJ, Clements CB. 2005. Historical and personality correlates to the violence patterns of juve-
niles tried as adults. Crim. Justice Behav. 32(1):69–96
Kyranides MN, Fanti KA, Petridou M, Kimonis ER. 2020. In the eyes of the beholder: investigating the effect
of visual probing on accuracy and gaze fixations when attending to facial expressions among primary and
secondary callous-unemotional variants. Eur. Child Adolesc. Psychiatry 29:1441–51
Lahey BB, Krueger RF, Rathouz PJ, Waldman ID, Zald DH. 2017. A hierarchical causal taxonomy of psy-
chopathology across the life span. Psychol. Bull. 143(2):142–86
Lahey BB, Rathouz PJ, Van Hulle C, Urbano RC, Krueger RF, et al. 2008. Testing structural models of
DSM-IV symptoms of common forms of child and adolescent psychopathology. J. Abnorm. Child Psychol.
36(2):187–206
Lahey BB, van Hulle CA, Singh AL, Waldman ID, Rathouz PJ. 2011. Higher order genetic and environmental
structure of prevalent forms of child and adolescent psychopathology. Arch. Gen. Psychiatry 68(2):181–89
Lawing K, Frick PJ, Cruise KR. 2010. Differences in offending patterns between adolescent sex offenders high
or low in callous-unemotional traits. Psychol. Assess. 22(2):298–305
Lawrence K, Campbell R, Skuse D. 2015. Age, gender, and puberty influence the development of facial emo-
tion recognition. Front. Psychol. 6:761
Leist T, Dadds MR. 2009. Adolescents’ ability to read different emotional faces relates to their history of
maltreatment and type of psychopathology. Clin. Child Psychol. Psychiatry 14(2):237–50
Little TD, Jones SM, Henrich CC, Hawley PH. 2003. Disentangling the “whys” from the “whats” of aggressive
behavior. Int. J. Behav. Dev. 27(2):122–33
Lockwood PL, Bird G, Bridge M, Viding E. 2013. Dissecting empathy: high levels of psychopathic and autistic
traits are characterized by difficulties in different social information processing domains. Front. Hum.
Neurosci. 7:760
Luby J, Lenze S, Tillman R. 2012. A novel early intervention for preschool depression: findings from a pilot
randomized controlled trial. J. Child Psychol. Psychiatry 53(3):313–22
Marsee MA, Frick PJ, Barry CT, Kimonis ER, Muñoz-Centifanti LC, Aucoin KJ. 2014. Profiles of the forms
and functions of self-reported aggression in three adolescent samples. Dev. Psychopathol. 26(3):705–20
Marsh AA, Blair RJR. 2008. Deficits in facial affect recognition among antisocial populations: a meta-analysis.
Neurosci. Biobehav. Rev. 32(3):454–65
Martin GB, Clark RD. 1982. Distress crying in neonates: species and peer specificity. Dev. Psychol. 18(1):3–9
McMahon RJ, Witkiewitz K, Kotler JS (Conduct Probl. Prev. Res. Group). 2010. Predictive validity of callous–
unemotional traits measured in early adolescence with respect to multiple antisocial outcomes. J. Abnorm.
Psychol. 119(4):752–63
Miller PA, Eisenberg N. 1988. The relation of empathy to aggressive and externalizing/antisocial behavior.
Psychol. Bull. 103:324–44

www.annualreviews.org • Conduct Disorders and Empathy Development 413

 Moffitt TE. 2018. Male antisocial behavior in adolescence and beyond. Nat. Hum. Behav. 2:177–86
Moffitt TE, Caspi A, Dickson N, Silva P, Stanton W. 1996. Childhood-onset versus adolescent-onset antisocial
conduct problems in males: natural history from ages 3 to 18 years. Dev. Psychopathol. 8:399–424
Moore AA, Blair RJR, Hettema JM, Roberson-Nay R. 2019. The genetic underpinnings of callous-
unemotional traits: a systematic research review. Neurosci. Biobehav. Rev. 100:85–97
Moul C, Hawes DJ, Dadds MR. 2018. Mapping the developmental pathways of child conduct problems
through the neurobiology of empathy. Neurosci. Biobehav. Rev. 91:34–50
Muñoz LC, Frick PJ, Kimonis ER, Aucoin KJ. 2008. Types of aggression, responsiveness to provocation, and
callous-unemotional traits in detained adolescents. J. Abnorm. Child Psychol. 36:15–28
O’Brien BS, Frick PJ. 1996. Reward dominance: associations with anxiety, conduct problems, and psychopathy
in children. J. Abnorm. Child Psychol. 24:223–40
Odgers CL, Caspi A, Broadbent JM, Dickson N, Hancox RJ, et al. 2007. Prediction of differential adult health
burden by conduct problem subtypes in males. Arch. Gen. Psychiatry 64(4):476–84
Odgers DL, Moffitt TE, Broadbent JM, Dickson N, Hancox RJ, et al. 2008. Female and male antisocial tra-
jectories: from childhood origins to adult outcomes. Dev. Psychopathol. 20:673–716
Pasalich DS, Dadds MR, Hawes DJ, Brennan J. 2011. Do callous-unemotional traits moderate the relative
importance of parental coercion versus warmth in child conduct problems? An observational study.
J. Child Psychol. Psychiatry 52(12):1308–15
Piquero AR, Jennings WG, Diamond B, Farrington DP, Tremblay RE, et al. 2016. A meta-analysis update on
the effects of early family/parenting training programs on antisocial behavior and delinquency. J. Exp.
Criminol. 12:229–48
Poulin F, Boivin M. 2000. Reactive and proactive aggression: evidence of a two-factor model. Psychol. Assess.
12(2):115–22
Richell RA, Mitchell DGV, Newman C, Leonard A, Baron-Cohen S, Blair RJR. 2003. Theory of mind and
psychopathy: Can psychopathic individuals read the ‘language of the eyes’? Neuropsychologia 41(5):523–26
Roth-Hanania R, Davidov M, Zahn-Waxler C. 2011. Empathy development from 8 to 16 months: early signs
of concern for others. Infant Behav. Dev. 34(3):447–58
Rothbart MK. 1981. Measurement of temperament in infancy. Child Dev. 52(2):569–78
Rothbart MK, Ahadi SA, Hershey KL. 1994. Temperament and social behavior in childhood. Merrill-Palmer
Q. 40(1):21–39
Sagi A, Hoffman ML. 1976. Empathic distress in the newborn. Dev. Psychol. 12(2):175–76
SAMHSA (Subst. Abus. Ment. Health Serv. Admin.). 2010. Comprehensive Community Mental Health Services
for Children and Their Families Program: Evaluation Findings: Annual Report to Congress. Washington, DC:
US Dep. Health Hum. Serv.
Schupp HT, Stockburger J, Codispoti M, Junghöfer M, Weike AI, Hamm AO. 2007. Selective visual attention
to emotion. J. Neurosci. 27(5):1082–89
Schwenck C, Gensthaler A, Romanos M, Freitag CM, Schneider W, Taurines R. 2014. Emotion recognition
in girls with conduct problems. Eur. Child Adolesc. Psychiatry 23(1):13–22
Schwenck C, Mergenthaler J, Keller K, Zech J, Salehi S, et al. 2012. Empathy in children with autism and
conduct disorder: group-specific profiles and developmental aspects. J. Child Psychol. Psychiatry 53(6):651–
59
Sharp C, Vanwoerden S, Van Baardewijk Y, Tackett JL, Stegge H. 2015. Callous-unemotional traits are as-
sociated with deficits in recognizing complex emotions in preadolescent children. J. Personal. Disord.
29(3):347–59
Singer T. 2006. The neuronal basis and ontogeny of empathy and mind reading: review of literature and
implications for future research. Neurosci. Biobehav. Rev. 30(6):855–63
Skeem JL, Polaschek DLL, Patrick CJ, Lilienfeld SO. 2011. Psychopathic personality: bridging the gap be-
tween scientific evidence and public policy. Psychol. Sci. Public Interest 12(3):95–162
Smith A. 2009. The empathy imbalance hypothesis of autism: a theoretical approach to cognitive and emo-
tional empathy in autistic development. Psychol. Record 59(2):489–510
Spinrad TL, Eisenberg N. 2017. Prosocial behavior and empathy-related responding: relations to children’s
well-being. In The Happy Mind: Cognitive Contributions to Well-Being, ed. MD Robinson, M Eid, pp. 331–
47. New York: Springer

414 Frick • Kemp

Spinrad TL, Gal DE. 2018. Fostering prosocial behavior and empathy in young children. Curr. Opin. Psychol.
20:40–44
Thomas R, Abell B, Webb HJ, Avdagic E, Zimmer-Gembeck MJ. 2017. Parent-child interaction therapy: a
meta-analysis. Pediatrics 140(3):e20170352
Thomas R, Zimmer-Gembeck MJ. 2007. Behavioral outcomes of parent-child interaction therapy and triple
P-positive parenting program: a review and meta-analysis. J. Abnorm. Child Psychol. 35:475–95
Thompson RA. 2012. Whither the preconventional child? Toward a life-span moral development theory. Child
Dev. Perspect. 6(4):423–29
Tremblay RE. 2010. Developmental origins of disruptive behaviour problems: the original sin hypothesis,
epigenetics and their consequences for prevention. J. Child Psychol. Psychiatry 51(4):341–67
Vachon DD, Lynam DR, Johnson JA. 2014. The (non)relation between empathy and aggression: surprising
results from a meta-analysis. Psychol. Bull. 140(3):751–73
Viding E, Blair RJR, Moffitt TE, Plomin R. 2005. Evidence for substantial genetic risk for psychopathy in
7-year-olds. J. Child Psychol. Psychiatry 46(6):592–97
Viding E, Frick PJ, Plomin R. 2007. Aetiology of the relationship between callous-unemotional traits and
conduct problems in childhood. Br. J. Psychiatry 190(Suppl. 49):s33–38
Viding E, Sebastian CL, Dadds MR, Lockwood PL, Cecil CA, et al. 2012. Amygdala response to preattentive
masked fear in children with conduct problems: the role of callous-unemotional traits. Am. J. Psychiatry
169(10):1109–16
Wagner NJ, Waller R, Flom M, Ronfard S, Fenstermacher S, Saudino K. 2020. Less imitation of arbitrary
actions is a specific developmental precursor to callous-unemotional traits in early childhood. J. Child
Psychol. Psychiatry 61:818–25
Wakschlag LS, Briggs-Gowan MJ, Carter A, Hill C, Danis B, et al. 2007. A developmental framework for
distinguishing disruptive behavior from normative misbehavior in preschool children. J. Child Psychol.
Psychiatry 48(10):976–87
Waller R, Gardner F, Hyde LW. 2013. What are the associations between parenting, callous–unemotional
traits, and antisocial behavior in youth? A systematic review of evidence. Clin. Psychol. Rev. 33(4):593–608
Waller R, Gardner F, Shaw DS, Dishion TJ, Wilson MN, Hyde LW. 2015. Callous-unemotional behavior
and early-childhood onset of behavior problems: the role of parental harshness and warmth. J. Clin.
Child Adolesc. Psychol. 44(4):655–67
Waller R, Trentacosta CJ, Shaw DS, Neiderhiser JM, Ganiban JM, et al. 2016. Heritable temperament path-
ways to early callous-unemotional behaviour. Br. J. Psychiatry 209(6):475–82
Waller R, Wagner NJ, Barstead MG, Subar A, Petersen JL, et al. 2020. A meta-analysis of the associations
between callous-unemotional traits and empathy, prosociality, and guilt. Clin. Psychol. Rev. 75:101809
Waller R, Wagner NJ, Flom M, Ganiban J, Saudino KJ. 2019. Fearlessness and low social affiliation as
unique developmental precursors of callous-unemotional behaviors in preschoolers. Psychol. Med. In
press. https://doi.org/10.1017/S003329171900374X
Ward MA, Theule J, Cheung K. 2016. Parent-child interaction therapy for child disruptive behaviour disor-
ders: a meta-analysis. Child Youth Care Forum 45:675–90
White SF, Frick PJ, Lawing K, Bauer D. 2013. Callous-unemotional traits and response to functional family
therapy in adolescent offenders. Behav. Sci. Law 31(2):271–85
WHO (World Health Organ.). 2018. International Classification of Diseases for Mortality and Morbidity Statistics.
Geneva: WHO. 11th rev. https://icd.who.int
Wilkinson S, Waller R, Viding E. 2016. Practitioner review: involving young people with callous unemotional
traits in treatment—does it work? A systematic review. J. Child Psychol. Psychiatry 57(5):552–65
Wilson K, Juodis M, Porter S. 2011. Fear and loathing in psychopaths: a meta-analytic investigation of the
facial affect recognition deficit. Crim. Justice Behav. 38(7):659–68
Woodworth M, Waschbusch D. 2008. Emotional processing in children with conduct problems and callous/
unemotional traits. Child Care Health Dev. 34(2):234–44
Wootton JM, Frick PJ, Shelton KK, Silverthorn P. 1997. Ineffective parenting and childhood conduct prob-
lems: the moderating role of callous-unemotional traits. J. Consult. Clin. Psychol. 65(2):301–8
Young SK, Fox NA, Zahn-Waxler C. 1999. The relations between temperament and empathy in 2-year-olds.
Dev. Psychol. 35(5):1189–97

www.annualreviews.org • Conduct Disorders and Empathy Development 415

 RELATED RESOURCES
Fleming GE, Kimonis ER. 2018. PCIT for children with callous-unemotional traits. In Handbook of Parent-
Child Interaction Therapy, ed. LN Niec, pp. 19–34. New York: Springer
Frick PJ. 2004. The Inventory of Callous-Unemotional Traits (ICU). Unpublished rating scale. https://sites01.
lsu.edu/faculty/pfricklab/icu/
Frick PJ. 2014. Clinical Assessment of Prosocial Emotions, Version 1.1 (CAPE 1.1). Unpublished clinician rating
of the Limited Prosocial Emotions specifier. https://sites01.lsu.edu/faculty/pfricklab/cape/

416 Frick • Kemp