Journal Pre-proof

A meta-analysis of the associations between callous-unemotional

traits and empathy, prosociality, and guilt

Rebecca Waller, Nicholas J. Wagner, Matthew G. Barstead, Anni

Subar, Jennifer L. Petersen, Janet S. Hyde, Luke W. Hyde

PII: S0272-7358(19)30321-6
DOI: https://doi.org/10.1016/j.cpr.2019.101809
Reference: CPR 101809

To appear in: Clinical Psychology Review

Received date: 29 April 2019

Revised date: 19 November 2019
Accepted date: 6 December 2019

Please cite this article as: R. Waller, N.J. Wagner, M.G. Barstead, et al., A meta-analysis of
the associations between callous-unemotional traits and empathy, prosociality, and guilt,
Clinical Psychology Review(2019), https://doi.org/10.1016/j.cpr.2019.101809

This is a PDF file of an article that has undergone enhancements after acceptance, such
as the addition of a cover page and metadata, and formatting for readability, but it is
not yet the definitive version of record. This version will undergo additional copyediting,
typesetting and review before it is published in its final form, but we are providing this
version to give early visibility of the article. Please note that, during the production
process, errors may be discovered which could affect the content, and all legal disclaimers
that apply to the journal pertain.

© 2019 Published by Elsevier.

 Journal Pre-proof

RUNNING HEAD: CU TRAITS, EMPATHY, PROSOCIALITY, AND GUILT

A Meta-Analysis of the Associations between Callous-Unemotional Traits and Empathy,

Prosociality, and Guilt

Rebecca Waller, Ph.D.1

Nicholas J. Wagner, Ph.D.2

of
Matthew G. Barstead, Ph.D.3
Anni Subar, B.A.4

ro
Jennifer L. Petersen, Ph.D.5

-p
Janet S. Hyde, Ph.D.6
Luke W. Hyde, Ph.D.4, 7, 8
re
lP

1
Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
2
Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
3
Department of Human Development and Quantitative Methodology, University of Maryland,
na

College Park, MD, USA

4
Department of Psychology, University of Michigan, Ann Arbor, MI, USA
ur

5
Department of Educational Foundations, University of Wisconsin, Whitewater, WI, USA
Jo

6
Department of Psychology, University of Wisconsin-Madison, Madison, WI, USA
7
Center for Human Growth and Development, University of Michigan, Ann Arbor, MI, USA
8
Institute for Social Research, University of Michigan, Ann Arbor, MI, USA

Correspondence: Rebecca Waller, Department of Psychology, Stephen A. Levin Building, 425

South University Avenue, Philadelphia, PA, 19104; Email: rwaller@sas.upenn.edu.

Conflict of interest statement: No conflicts declared. This research did not receive any specific
grant from funding agencies in the public, commercial, or not-for-profit sectors.
 Journal Pre-proof

of
ro
-p
re
lP
na
ur
Jo
 Journal Pre-proof

RUNNING HEAD: CU TRAITS, EMPATHY, PROSOCIALITY, AND GUILT

A Meta-Analysis of the Associations between Callous-Unemotional Traits and Empathy,

Prosociality, and Guilt

of
ro
-p
re
lP
na
ur
Jo
 Journal Pre-proof

Abstract

Antisocial behavior is harmful, financially costly to society, and hard to treat. Callous-

unemotional (CU) traits, which predict greater risk for antisocial behavior, are defined in

theoretical and diagnostic models as representing low empathy, guilt, and prosociality. However,

no meta-analytic reviews have systematically integrated the findings of studies that have reported

associations between measures of CU traits and empathy, guilt, or prosociality, or potential

moderators of these associations, including gender, age, severity of antisocial behavior, and

of
informant (i.e., self or other reports of measures). To address this gap in the literature, we

ro
conducted three separate meta-analyses exploring the association between CU traits and

-p
empathy, guilt, and prosociality. In follow-up analyses, we explored associations between CU
re
traits and affective versus cognitive empathy. The results revealed statistically significant and

moderate-to-large negative associations between measures of CU traits and empathy (ρ=-.57),

lP

guilt (ρ=-.40), and prosociality (ρ=-.66). The negative association between CU traits and
na

cognitive empathy was stronger when the informant was a parent or teacher rather than the child,

and in younger children. CU traits were also more strongly related to cognitive empathy than
ur

affective empathy when the informant was a parent or teacher rather than the child, and in
Jo

younger children. The findings establish that CU traits are moderately-to-strongly correlated with

the presence of callous (low empathy), uncaring (low prosociality), and remorseless (low guilt)

behaviors.

Keywords: callous-unemotional; empathy; guilt; meta-analysis; prosociality.

 Journal Pre-proof

Childhood antisocial behavior refers to delinquent and norm-violating acts, such as

aggression, violence, theft, and truancy. Antisocial behavior is devastating to long-term well-

being, with antisocial children showing higher rates of violent and drug-related crime, poorer

mental health, and worse economic outcomes as adults compared to children without antisocial

behavior (Colman, et al., 2009; Moffitt, Caspi, Harrington, & Milne, 2002). Heterogeneity within

antisocial behavior is a barrier to improving our knowledge of its etiology and treatment. Thus,

research has sought to identify subtypes of childhood antisocial behavior with specific etiologies

of
and treatment needs. One approach focuses on the presence of callous-unemotional (CU) traits,

ro
defined by low empathy, lack of remorse, and insensitivity to the distress of others (Frick,

-p
O'Brien, Wootton, & McBurnett, 1994; Frick, Ray, Thornton, & Kahn, 2014b). The construct of
re
CU traits has become highly influential within clinical psychology in a relatively short time

period, with the number of empirical articles investigating CU traits escalating rapidly since the
lP

1990s (Figure 1). CU traits demarcate an important subgroup of antisocial youth at risk for
na

severe, chronic, and violent patterns of offending (Frick, Ray, Thornton, & Kahn, 2014a; Frick,

et al., 2014b; Frick & White, 2008). CU traits also predict severe and stable aggression across
ur

development even in community samples beginning as young as age 3 (Waller, et al., 2016a;
Jo

Waller & Hyde, 2018; Waller, et al., 2017). Notably, it is almost ubiquitous that the first

paragraph of any paper on CU traits, including this one, define CU traits by drawing on some

version of the following phrase: “a lack of guilt, a lack of empathy, and shallow affect” (p. 861,

Frick, 2016; p. 625, Kimonis, et al., 2016). However, no prior meta-analytic review has

quantitatively established the correlation between CU traits and empathy, guilt, or prosociality

during childhood.

Theoretical Background of CU Traits

 Journal Pre-proof

The theoretical origins of CU traits can be found in decades of research examining

psychopathic traits among incarcerated adults (Hare, 1999; Hare & Neumann, 2008).

Psychopathy refers to a constellation of extreme behavioral and personality features, including

impulsivity, manipulativeness, deceitfulness, and shallow affect, which together predict severe

antisocial behavior and criminal recidivism (Hare, 1999; Hare & Neumann, 2008; Neumann,

Hare, & Pardini, 2015). Factor-analytic studies in adults establish that items used to portray the

personality features of psychopathy, including shallow affect, deceitfulness, and low empathy,

of
form a distinct factor from items tapping harmful lifestyle and antisocial behaviors (Neumann, et

ro
al., 2015). In one of the first efforts to operationalize precursors of psychopathy in children,

-p
Frick and colleagues designed the 20-item Psychopathy Screening Device (PSD), which later
re
became known as the Antisocial Process Screening Device (APSD). The APSD combines the

psychological and harmful personality features of psychopathy into a subtyping approach for
lP

antisocial behavior that is tailored for use with younger populations (Frick, 2016). The work was
na

influenced by the “undersocialized aggressive” subtype of childhood Conduct Disorder that

appeared in DSM-III (American Psychiatric Association, 1980), which was based, among other
ur

things, on children failing to maintain social relationships and exploiting others (Quay, 1993).
Jo

Empirical studies of the APSD largely reported that CU traits form a separate factor from

other constructs relevant to psychopathy, such as narcissism, impulsivity, and conduct problems

(Barry, et al., 2000; Christian, Frick, Hill, Tyler, & Frazer, 1997). More recently, other measures

have been developed to assess CU traits, including the 24-item Inventory of Callous-

Unemotional Traits (ICU; Frick, 2004), the Interpersonal-Callousness scale (Pardini, Obradovic,

& Loeber, 2006), and the CU traits scale of the Youth Psychopathic Inventory (Andershed,

Hodgins, & Tengström, 2007). These measures share items assessing the presence of callousness
 Journal Pre-proof

and uncaring (e.g., “I do not care who I hurt to get what I want” [ICU]) and low or reversed

scores for items tapping guilt (e.g., “I feel remorseful when I do something wrong” [IC]),

prosociality (e.g., “I do things to make others feel good” [ICU]), and empathy (e.g., “I am

concerned about the feelings of others” [ICU/APSD]).

Theoretical Background of Empathy, Prosociality, and Guilt

This brief review highlights that there exists both construct and item overlap between

measures of CU traits and normative socioemotional processes, such as empathy, prosociality,

of
and guilt, which have been studied for many decades and form the foundation of cooperative and

ro
moral behavior (Kochanska, 1997; Kochanska, Gross, Lin, & Nichols, 2002). First, empathy is

-p
defined as the ability to perceive and resonate with the emotions being felt by another person
re
(Eisenberg, Spinrad, & Knafo-Noam, 2015). Empathy consolidates into a moderately stable

characteristic in the second and third years of life (Davidov, Zahn‐Waxler, Roth‐Hanania, &
lP

Knafo, 2013). Individual differences in the tendency to experience empathy have important and
na

cascading implications for social functioning across development (Stern & Cassidy, 2018). Low

empathy is related to poor social understanding in childhood (Findlay, Girardi, & Coplan, 2006)
ur

and risk for aggression violence (Jolliffe & Farrington, 2004). Traditionally, research
Jo

distinguishes between affective empathy (i.e., experience of shared emotion elicited by another’s

emotional expressions) versus cognitive empathy (i.e., ability to understand the feelings and

perspectives of another) (Shamay-Tsoory & Aharon-Peretz, 2007). Preliminary research and

theory suggests that children with CU traits show more severe deficits in affective empathy

compared to cognitive empathy (Jones, Happé, Gilbert, Burnett, & Viding, 2010; Waller, Hyde,

Grabell, Alves, & Olson, 2015).

Second, the moral emotion of guilt is defined as the aversive feeling that arises from
 Journal Pre-proof

knowledge that your actions may have harmed someone else or that you have broken the rules,

norms, or expectations (Nelissen & Zeelenberg, 2009). Such negative feelings are critical for

motivating transgressors to seek forgiveness, make amends, avoid further acts of harm or rule-

breaking, and repair any social damage caused (Baumeister, Stillwell, & Heatherton, 1994). In

particular, guilt promotes behaviors conveying information that the transgressor is suffering for

his/her actions and did not intend harm, which promotes forgiveness, affiliation and contributes

to cooperation between members of a society (Baumeister, et al., 1994). Developmental research

of
suggests that children become aware of their misdeeds from age 2 onwards (Kochanska, et al.,

ro
2002), when they manifest both verbal and non-verbal signs of guilt, including attempts to repair

-p
interpersonal harm against others (Vaish, 2018). Importantly, low guilt is linked to externalizing
re
problems (Ferguson, Stegge, Miller, & Olsen, 1999) and psychopathy (Raine & Yang, 2006).

Finally, prosociality refers to both proactive or reactive responses to the needs of others
lP

to bring assistance or promote well-being (Eisenberg, et al., 2015). Evolutionary perspectives

na

emphasize that other-oriented behaviors improve genetic survival through socially reinforcing

altruism (Sober & Wilson, 1998). Prosocial behaviors often arise from empathy, which drives
ur

“altruistically-motivated prosociality”. However, other forms of prosocial behavior are driven by

Jo

more self-serving motivations, including desire for approval, reward, or reciprocity (Eisenberg,

et al., 2015). Prosocial behavior in response to others’ needs emerges around 30-months old

(Brownell, 2013). Low prosociality across development is linked to antisocial behavior,

including lying and fighting (Meltzer, Gatward, Goodman, & Ford, 2000) and to psychopathy in

adults (Hare & Neumann, 2008).

Leveraging Meta-analytic Techniques to Achieve Study Goals

Although deficits in guilt, empathy, and prosociality are cited as being central to the
 Journal Pre-proof

definition and measurement of CU traits (see Frick, et al., 2014a, 2014b; Kochanska, 1997;

Kochanska, et al., 2002), no systematic reviews exist that have quantified the magnitude of any

associations with CU traits. Addressing this gap in the literature is important for several reasons.

First, there exists clear circularity in the way we define CU traits. On a very simple level, a meta-

analysis can help to inform whether we are simply using different terminology (i.e., “CU traits”)

to talk about what might be the same construct (i.e., low empathy, prosociality, and guilt).

Answering this question is consistent with the idea that “we should not think things are different

of
if they could be the same. Equally, Occam's razor indicates that we should not think behavior to

ro
be complicated if we can make it simple by re-expressing, or reformulating, our variables” (p.

-p
86, Tukey, 1969). Thus, if strong negative correlations exist between CU traits with empathy,
re
guilt, or prosociality (i.e., r=.70), we might conclude that our measurement and etiological

models of CU traits might be improved by more explicitly expanding on decades of work

lP

focused on empathy, prosociality, and guilt within developmental psychology and applying this
na

work within clinical contexts, particularly by characterizing CU traits as a multidimensional

construct representing a constellation of deficits across empathy, prosociality, and guilt.

ur

Second, the origins of most measures of CU traits can be found in items used to assess
Jo

psychopathy in adult and male offenders. Thus, the development of the CU traits construct

proceeded in a “top-down” developmental progression, from adult psychopathy, to clinic-

referred samples of adolescents, and most recently to younger community samples in early- and

middle-childhood. However, there is much that we can learn about antisocial behavior and

psychopathy by proceeding in a “bottom-up”, developmentally-oriented manner, especially with

growing consensus that psychopathology is evident in the preschool years (Angold & Egger,

2007) and evidence that disruptions to empathy and prosociality during this time signal risk for
 Journal Pre-proof

CU traits (Waller & Hyde, 2018). Indeed, as outlined above, a much larger literature with a

longer history has explored the development of empathy, guilt, and prosociality (Eisenberg, et

al., 2015; Kochanska, 1997; Kochanska, et al., 2002), as well as the correlation of these

characteristics with antisocial behavior and psychopathy (Jolliffe & Farrington, 2004).

Alternatively, if CU traits are only modestly-moderately correlated (range, r=.20-.40) with low

empathy, prosociality, and guilt, our findings would provide a theoretical foundation for a

renewed focus on other correlates (i.e., better defining the nomologic network for CU traits) that

of
could inform definitions, measurement, or etiological models of CU traits.

ro
Third, the CU traits construct was first developed by extending the adult psychopathy

-p
construct to clinic-referred samples of youth. Accordingly, its development occurred in the
re
context of samples with over-representation of males or that were entirely male (Frick & White,

2008). Studies of adults suggest that the underlying factor structure of psychopathy measures
lP

may differ between men and women (Colman, et al., 2009). However, few studies have directly
na

addressed the question of whether CU traits show similar correlates among boys and girls.

Gender is related to differences in absolute levels of CU traits, antisocial behavior, empathy,

ur

prosociality, and guilt. Boys show significantly higher CU traits (Essau, Sasagawa, & Frick,
Jo

2006) and antisocial behavior (Berkout, Young, & Gross, 2011), whereas girls show significantly

higher empathy (Hoffman, 1977). However, differences in absolute levels do not imply that the

associations between CU traits and empathy, prosociality, and guilt will differ for males and

females. For example, in one study the relationship between CU traits and higher antisocial

behavior was similar among boys and girls during early childhood (Longman, Hawes, &

Kohlhoff, 2016). An exploration of gender as a moderator of the associations between CU traits

and empathy, guilt, and prosociality will help to clarify the correlates of CU traits.
 Journal Pre-proof

Current Review

To provide a foundation upon which future work can more fully incorporate CU traits

into developmental and clinical models of psychopathology, we quantitatively summarized

studies reporting an association between CU traits and measures of empathy, prosociality, or

guilt, which were each explored within separate meta-analytic models. Based on the findings of a

recent network analysis study of the PCR-R among incarcerated adults that found “low empathy”

to be the most central characteristic within the psychopathy network (Verschuere, et al., 2017),

of
we predicted that low empathy would be the strongest correlate of CU traits, with prosociality

ro
and guilt showing moderate-to-high correlations with CU traits consistent with the underlying

-p
theoretical development of construct. Consistent with prior studies that have reported differential
re
relationships between CU traits and affective empathy versus cognitive perspective-

taking/Theory of Mind (Jones, et al., 2010; Waller, et al., 2015), we hypothesized that CU traits
lP

would be more strongly related to lower affective empathy than cognitive empathy. We also
na

examined whether relationships differed by gender, age, or sample type. Given the paucity of

studies exploring differential correlates of CU traits based on gender, age or severity of antisocial
ur

behavior, we made no directional hypotheses about these potential moderators. Finally, to

Jo

explore informant method effects, we tested moderation of the relationships between variables

based on the informant for CU traits and either empathy, prosociality, or guilt being the same

person or across informants (e.g., child vs. parent/teacher reports).

Method

Search Strategy

Studies were identified by a computerized search of electronic databases (MEDLINE,

PsycINFO, and Web of Science). The electronic search was run on May 29th 2019 and was based
 Journal Pre-proof

on three sets of terms: (1) those relating to CU traits or psychopathy (e.g., callous, callous-

unemotional, psychopathy); (2) those relating to empathy, prosociality, and guilt (e.g., empathic,

prosocial, remorse). Searches were limited to studies of children and adolescents. To ensure that

we were accessing recent conceptualizations of CU traits as derived from the adult construct of

psychopathy, database searches were limited to studies published after 1987 when the first paper

on the Psychopathy Checklist was published and seven years prior to the publication of the first

study of CU traits (Frick, et al., 1994). Reference lists and forward citations of selected eligible

of
articles were examined to identify any studies missed in the database searches.

ro
Inclusion and Exclusion Criteria

-p
We had five inclusion criteria: (1) empirical studies (published or unpublished) reporting
re
an association between CU traits and a measure of empathy, guilt, and/or prosociality; (2) studies

that employed validated measure of CU traits (e.g., ICU, Frick, 2004; CU traits scale of the
lP

APSD, Frick & Hare, 2001), “post-hoc, author-created” measures using a combination of items
na

from different questionnaires that tapped the CU construct (Hawes & Dadds, 2005; Pardini, et

al., 2006) or callousness/CU traits scales from a psychopathy measure (e.g., CU factor of the
ur

Youth Psychopathic traits Inventory, Andershed, et al., 2007); (3) studies that included trait-
Jo

based questionnaire measure of empathy, guilt, or prosociality; (4) samples with a mean age of

18 or younger; (5) studies published in English. We excluded studies if they did not meet these

criteria. Notably, we excluded studies that examined context-specific behavioral or performance

empathy measures within a laboratory setting, including studies that used tasks where children

responded to vignettes or imaging studies using “empathy-eliciting” tasks. We excluded these

studies to focus on trait-like empathy, rather than state-like empathic responses that could be

influenced by context (Zaki, 2014), and because of heterogeneity across tasks and methods.
 Journal Pre-proof

Selection of Studies

All studies were screened by the first, second, and fourth authors. Disagreements about

whether inclusion criteria were met were resolved by the first and last authors. The electronic

database search identified 780 records. Within the 780 records identified from the initial search,

there were 273 duplicates, which were excluded. In addition, 13 records were identified and

screened following a search of the reference lists of relevant reviews and identified records.

Accordingly, we screened the title and abstracts of 520 records. After excluding a further 384

of
articles based on a screening of titles and abstracts, the full text of 136 articles was evaluated in

ro
detail in relation to our inclusion criteria. At this stage, we removed an additional 70 studies

-p
because: (1) they did not have a measure of CU traits, (2) they had a measure of CU traits, but no
re
trait-based questionnaire measure of guilt, empathy, or prosociality, or (3) they did not assess a

sample with a mean age of 0-18 years old. We removed 4 articles that shared the same dataset.
lP

Finally, we contacted 14 authors for additional data when sufficient information was not reported
na

that would have allowed us to compute effect sizes. From those 14 studies, 11 authors (79%)

provided usable data. One author was unable to provide us with requested data and two did not
ur

respond to the request. We contacted 11 other authors to request additional information about
Jo

cognitive and affective empathy subscales if only total empathy was reported, and vice versa. Of

those 11 authors, 8 (72.7%) provided the additional requested information. Our final pool

included 59 studies. The flow of studies through the screening protocol is shown in Figure S1.

Extraction of data

The information extracted from each study included: (a) first author and year of

publication, country, study design; (b) sample demographics; (c) CU traits measure (i.e., scale

used, informant); (d) empathy/prosociality/guilt measure (i.e., scale used, informant); (e) CU
 Journal Pre-proof

traits and empathy/prosociality/guilt data (i.e., statistics on correlations or group differences,

including means, standard deviations, t values, F values, and r values). For the moderation

analysis, we extracted the gender proportions, age, type of sample assessed (community/high risk

vs. clinic-referred/forensic), CU traits respondent (self vs. other) and outcome respondent (self

vs. other). Consistent with an open science framework, coding for the extraction of data is

publicly available via Github (https://github.com/matgbar/Meta-Analysis_Waller_et_al).

Meta-Analytic Strategy

of
We conducted all analyses using the metafor package for R version 3.5.1 (R Core Team,

ro
2018; Viechtbauer, 2010). Consistent with guidelines for psychometric meta-analyses, we used

-p
reliability estimates to correct for attenuation of correlations that occurs due to measurement
re
error (Schmidt & Hunter, 2014). When these values were not reported (CU traits, n=8 [9.30%];

Outcome, n=17 [19.78%]), we imputed values using the Mice package in R averaging values
lP

returned in five imputed data sets (van Buuren & Groothuis-Oudshoorn, 2011; Figure S2).
na

When effects were presented as mean differences, we applied a correction based on the

reliability of the outcome measure (e.g., empathy scores) prior to transforming the corrected
ur

standardized mean difference and its variance to a correlation scale using a well-established
Jo

formula (Borenstein, Hedges, Higgins, & Rothstein, 2010). If effects were reported separately by

gender they were treated as point estimates for independent populations of boys and girls.

Using these attenuation-corrected effects and their variances, we examined unconditional

random effects models for each of empathy, guilt, and prosociality. For a subset of studies that

included separate effects for affective and cognitive empathy, we examined unconditional

models that tested the (a) association between affective empathy and CU traits, (b) association

between cognitive empathy and CU traits, and (c) magnitude of the difference between them.
 Journal Pre-proof

Calculation of variance terms for dependent effects in this latter model required that we include

the within-sample correlation between affective and cognitive empathy to account for the overlap

of these constructs. In instances in which we were unable to obtain a measure of association

between cognitive and affective empathy, we took a conservative approach of assuming the

correlation was 0. This choice is conservative in the sense that these two measures are thought to

be positively correlated in general, meaning that variance estimates for the difference in CU-

affective empathy versus CU-cognitive empathy relations would be somewhat inflated without

of
an estimate of shared variance between the two outcomes, thereby increasing the likelihood of

ro
failing to reject the null hypothesis that there is no difference.

-p
To identify the potential influence of publication bias, we employed a multifaceted
re
approach, including a visual inspection of funnel plots generated from the unconditional models

involving uncorrected correlations, examining weighted regressions of funnel plot asymmetry

lP

using standard error, and comparing a trim-and-fill model utilizing the L0 estimator. In general,
na

systematic bias in an obtained set of effect sizes is thought to be present if there is considerable

asymmetry in funnel plots, a weighted regression returns a significant test statistic, and/or trim-
ur

and-fill models substantively differ from standard random effects models. To verify statistical
Jo

estimates, we also examined all models using SPSS and macros for meta-analysis provided by

Lipsey and Wilson (2001) and found estimates that were very close to those obtained using the R

metafor package for the attenuation-corrected and non-corrected estimates (Lipsey & Wilson,

2001). Thus, we focus the presentation of results on estimates derived from analyses using

metafor package for R (R Core Team, 2018; Viechtbauer, 2010). Results using SPSS and macros

are available via GitHub (https://github.com/matgbar/Meta-Analysis_Waller_et_al).

After assessing the basic properties of each unconditional model, we explored potential
 Journal Pre-proof

moderation of the associations between CU traits and empathy, guilt, prosociality, affective

empathy, and cognitive empathy in a series of univariate models (i.e., one moderator entered

each model at a time). Consistent with our study goals, we explored whether the associations of

interest differed by sample age (explored as a continuous moderator), proportion of females in

the sample (explored as a continuous moderator), and severity of antisocial behavior (binary

moderator, coded as clinical/forensic, 1 vs. community sample, 0). We also tested whether the

informant for the CU traits and outcome measures being the self (1) versus another informant (0;

of
parent teacher) influenced the magnitude of the associations. Of note, the informant for CU traits

ro
in each sample tended to be the same the informant for the outcome variable (95% of the

-p
effects), making these two study-level variables highly collinear, and prohibiting us from testing
re
cross-informant effects for the CU traits and outcome measure as an additional moderator.

Finally, in a post-hoc moderation analyses, having amassed our study pool, we noted that 22
lP

studies had used the ICU (Frick, 2004), with the remaining studies using other measures (e.g.,
na

YPI and PCL:YV). Given the burgeoning use of the ICU since it was made available in 2004, we

tested whether associations between CU traits and empathy, prosociality, and guilt differed when
ur

the measure of CU traits was the ICU (coded as 1) versus other measures (coded as 0). We used
Jo

Knapp and Hartung’s adjustment when testing the significance of moderators in these models to

reduce Type I error inflation that can occur with other approaches (Viechtbauer, 2010).

Results

Study Characteristics

The search and review procedures led to a final sample of 59 articles, containing a total

of 106 relevant effects. Within this total study pool, 36 articles (36 effect sizes) were included in

the empathy meta-analysis (N=10,252); 17 articles (19 effect sizes) were included in the
 Journal Pre-proof

prosociality meta-analysis (N=12,082); and 4 articles (4 effect sizes) were included in the guilt

meta-analysis (N=434). Sample sizes ranged from 37 to 6,791 individuals. The weighted mean

age of included samples was 12.07 years (range = 3.42–17.54 years old). We included proportion

of female participants (weighted average proportion of females was .42, range = 0–1) and sample

type (i.e., clinical/forensic vs. community) as moderators. The characteristics of included studies

are summarized in Table 1. Data files are available at https://github.com/matgbar/Meta-

Analysis_Waller_et_al.

of
Unconditional Models

ro
Total Empathy. There were 36 separate effects included in the random effects model for

-p
total empathy (Table S1). The estimated association between CU traits and total empathy in the

model was large, negative, and significant (ρ=-.57) (Table 2, Figures 2 and S3). Supporting the
re
use of a random effects model, the observed Q-statistic was significant (Q=426.71, p<.001). In
lP

terms of publication bias, there was some asymmetry upon inspection of the funnel plot. In line
na

with this visual inspection, the weighted regression test was significant (t=2.51, df=34, p=.02).

However, a trim-and-fill model failed to identify any absent effects.

ur

Affective Empathy. There were 23 separate effects included in the random effects model
Jo

for affective empathy (Table S2). The estimated association between CU traits and affective

empathy was moderate, negative, and significant (ρ=-.33) (Table 2, Figures 2 and S3).

Supporting the use of a random effects model, the observed Q-statistic was significant

(Q=485.33, p<.001). Visual inspection of the funnel plot did not reveal an obvious pattern of

asymmetry, and this subjective appraisal was supported by the regression test (t=.90, df=21,

p=.38). A trim-and-fill model did not identify absent effects.

Cognitive Empathy. There were 19 separate effects included in the random effects model
 Journal Pre-proof

for cognitive empathy (Table S3). The estimated association between CU traits and cognitive

empathy was moderate, negative, and significant (ρ=-.43) (Table 2, Figures 2 and S3).

Supporting the use of a random effects model, the observed Q-statistic was significant

(Q=236.72, p<.001). While the funnel plot appeared to show an asymmetric distribution with

fewer effects distributed to the left side of the plot, neither the regression model testing for

asymmetry (t=1.69, df=22, p=.11), nor a trim-and-fill model were significant.

Affective versus Cognitive Empathy. Measures of both affective and cognitive empathy

of
were included in a total of 23 samples (Table S4). Of the 23 effects included in the model, the

ro
correlation between affective and cognitive empathy was reported in 13 cases (range, r=-

-p
.52−.76). Prior to modeling, we calculated difference scores by subtracting CU-cognitive
re
empathy effects from CU-affective empathy effects in each sample. If a resulting difference was

negative, it would indicate that the expected inverse relation was stronger between CU traits and
lP

affective empathy than between CU traits and cognitive empathy. In contrast to our hypothesis,
na

the model revealed no difference in the strength of association between CU traits and affective

empathy compared to the association between CU traits and cognitive empathy (Δρ=.07) (Table
ur

2, Figures 2 and S3).

Jo

Prosociality. There were 19 separate effects included in the random effects model testing

prosociality (Table S5). The estimated association between CU traits and prosociality was large,

negative, and significant (ρ=-.66) (Table 2, Figures 2 and S3). Supporting the use of a random

effects model, the observed Q-statistic was significant (Q= 224.69, p<.001). In terms of

publication bias, visual inspection of the funnel plot indicated the possibility of an asymmetric

distribution of effects, although this subjective appraisal was unsupported by the regression test

(t=0.32, df=17, p=.76). In line with the visual inspection of the funnel plot, a trim-and-fill model
 Journal Pre-proof

identified several missing effects below the aggregated correlation

(https://github.com/matgbar/Meta-Analysis_Waller_et_al). However, inclusion of effects at the

specified locations did not alter the significance of the estimated relation between CU traits and

prosociality, nor impact the substantive interpretation regarding the magnitude of the uncorrected

estimated effect.

Guilt. There were only 4 effects describing the relation between CU traits and measures

of guilt (Table S6), rendering many model- and bias-checking steps moot. For completeness,

of
however, we provide a fixed effect estimate of the relation between CU traits, which was

ro
moderate, negative, and significant (ρ =-.40) (Table 2, Figures 2 and S3).

Moderation Models
-p
re
Tests of moderation revealed little evidence of moderation, with four exceptions (Table

3). The association between CU traits and cognitive empathy was moderated by sample age, with
lP

stronger associations observed in younger samples (Table 3; Figure 3A). Self-reports of

na

cognitive empathy, while still significantly and negatively related to CU traits, were not as

strongly related to CU traits compared to when cognitive empathy and CU traits scores were
ur

reported by another informant (i.e., parent/teacher; Table 3; Figure 4A). In addition, the
Jo

magnitude of the association between CU traits and cognitive versus affective empathy varied as

a function of age and informant. There was a stronger association between lower cognitive

empathy and CU traits than between affective empathy and CU traits in younger children,

whereas there was a stronger association between lower affective empathy and CU traits than

between cognitive empathy and CU traits in older children (Table 3; Figure 3B). Similarly,

there was a stronger association between lower cognitive empathy and CU traits than between

affective empathy and CU traits when cognitive empathy and CU traits scores were reported by
 Journal Pre-proof

another informant (i.e., parent/teacher (Table 3, Figure 4B).

Discussion

The current meta-analysis represents a timely review of the associations between CU

traits and empathy, prosociality, and guilt; constructs that are theorized to be core to definitions

of CU traits. We found moderate associations between CU traits and empathy (ρ=-.57),

prosociality (ρ=-.66), and guilt (ρ=-.40), although these were smaller in magnitude than had been

hypothesized, particularly for empathy and guilt. When we did not correct for attenuation, the

of
estimates were only modest-to-moderate in magnitude (i.e., range, ρ=-.25 to -.49). Further, in

ro
contrast to hypotheses, we found no difference in the strength of the association between CU

-p
traits and affective versus cognitive empathy. Finally, we found very little evidence for
re
moderation of the associations between CU traits and prosociality, empathy, and guilt with four

exceptions based on informant and age: CU traits were more strongly related to lower cognitive
lP

empathy when the informant was a parent or teacher (rather than the child) and in younger
na

children. There were also differences in the relative magnitude of the association between CU

traits and affective versus cognitive empathy contingent on age and informant. Broadly, the
ur

finding that deficits in empathy, prosociality, and guilt were significantly related to CU traits is
Jo

consistent with expectations given that these constructs are core to definitions of adult

psychopathy and the historical development of the construct of CU traits (Frick, 2016; Hare &

Neumann, 2008). However, our findings are also important for provoking continued evaluation

of the core correlates of CU traits. In the following sections, we discuss the significance of our

findings and evaluate how they can inform definitions, measurement, and developmental models

of CU traits.

Prosociality and CU traits

 Journal Pre-proof

In contrast our hypothesis that empathy would be most strongly related to CU traits, the

negative correlation with the largest magnitude was between CU traits and a lack of prosociality.

One explanation for this finding is that displays of prosocial behavior may be easier to recall

about oneself or observe in another person than the internal experience of empathy. At the same

time, some forms of prosocial behavior arise in the context of empathy, which motivates the

desire to help another after emotionally resonating with their suffering or needs (i.e.,

“altruistically-motivated”). To that end, the correlation we found between measures of low

of
prosociality and CU traits may also reflect the fact that both these constructs represent the

ro
observable and behavioral manifestation of an underlying deficit in empathy. Indeed, while a

-p
lack of prosocial behavior is evident in a host of psychopathologies, including other psychiatric
re
disorders, such as borderline personality disorder (Crick, Murray-Close, & Woods, 2005) and

anorexia nervosa (Morris, Bramham, Smith, & Tchanturia, 2014), the inference made with
lP

regards to a lack of prosocial behavior in the case of CU traits, is that of an underlying deficit in
na

prosocial emotions – the emotional experiences that give rise to prosocial behavior.

A deficit in prosocial emotions is also reflected in the four-item DSM-5 “limited

ur

prosocial emotions” LPE) specifier for conduct disorder with CU traits, although the specifier
Jo

itself makes no reference to prosocial behavior. The LPE specifier is diagnosed if a child

presents with two or more of the following characteristics over at least 12 months and in multiple

relationships or settings: lack of remorse or guilt, lack of empathy, lack of concern about

performance, and shallow affect. While the nomenclature difference between prosocial behavior

versus emotions implies a conceptual distinction, our review suggests that the diagnostic criteria

for the LPE specifier, or measures used to assess for the specifier, could be expanded to assess

outward behavioral examples of a lack of prosocial behavior. For example, although clinical
 Journal Pre-proof

assessments of the DSM-5 LPE specifier are still undergoing development, the working manual

of the Clinical Assessment of Prosocial Emotions (CAPE; Frick, 2013) includes an interview

item focused on whether the child does “nice things for other people, even if there is nothing in it

for him/herself” requiring examples and frequency ratings, which appears to be a more explicit

assessment of prosocial behavior. Other studies have also used “hybrid measures” that combine

traditional CU traits measures, such as the APSD CU traits scale, with measures of prosociality,

such as the SDQ (Hawes & Dadds, 2005). A stronger integration between the developmental

of
literature on prosocial behavior and the clinical psychology literature examining CU traits could

ro
serve to better inform not just measurement, but etiological models and treatment approaches.

Empathy and CU traits

-p
re
While the strongest correlation was between low prosociality and CU traits, we also

found a moderate-to-large correlation between CU traits and low empathy. A review of the items
lP

included in the measures of CU traits and empathy revealed less item contamination than might
na

be expected given the conceptual history of CU traits. In particular, there was some distinction

between measures of CU traits versus measures of empathy based on items assessing empathic
ur

arousal (i.e., feeling “as” someone) and empathic concern or sympathy (i.e., “feeling for”
Jo

someone) (Hein & Singer, 2008). Specifically, many of the studies that used questionnaire and

trait-based assessments of empathy included items specifically mapping onto empathic arousal,

such as, “seeing a boy who is crying makes me feel like crying” (Bryant Index of Empathy;

Bryant, 1982). However, items on measures of CU traits that had to do with empathy used by

studies assessed something closer to the construct of sympathy or empathic concern, such as “I

am concerned about the feelings of others” (ICU). This variation in operationalization could

partly explain the lower-than-predicted correlation we found between CU traits and empathy
 Journal Pre-proof

(i.e., less item-contamination; although prosociality measures also had low item-contamination).

Thus, our knowledge of CU traits may be advanced if future studies include items tapping low

empathic arousal or emotional contagion to assess CU traits. Alternatively, etiological models

may be improved by continuing to exclude such items and considering low empathic arousal as a

specific developmental precursor to CU traits. That is, at some level, we must decide whether

empathy, as measured by items or observations of empathic arousal or emotion contagion, are

part of the CU traits construct or part of its external nomologic or developmental network.

of
Importantly, while deficits in empathic arousal can be present very early in life, they are

ro
buffered or exacerbated by specific impairments in cognitive capabilities, including the

-p
“…ability to experience and understand what others feel without confusion between oneself and

others” (Decety & Lamm, 2006, p. 1146). Using moderation analysis, we tested the hypothesis
re
that CU traits are more strongly related to deficits in affective empathy relative to cognitive
lP

empathy. In contrast to predictions, we found no difference in the overall magnitude of the

na

associations between CU traits and deficits in affective versus cognitive empathy. Thus, the

findings point to the fact that deficits in both affective and cognitive empathy are correlated with
ur

CU traits. At the same time, we note that items tapping cognitive empathy may differ somewhat
Jo

to the constructs of perspective-taking or Theory of Mind that have been assessed in studies

reporting children with CU traits to show intact cognitive understanding of the situation or

knowledge of others (i.e., tasks without an explicit emotion recognition or interpretation; Jones,

et al., 2010; Waller, et al., 2015). Future studies are needed to identify sociocognitive deficits

that are specific to children with high CU traits, and the extent to which this profile is

characterized by intact perspective taking or Theory of Mind skills based on cognitive processing

capacities, but deficits in empathy in the context of emotion processing (Jones, et al., 2010).
 Journal Pre-proof

Related to the role of cognitions for understanding empathy deficits is research that has

focused on the motivations that drive people to avoid (e.g., suffering, material costs) or approach

(social desirability) engaging with others’ emotions and needs (Zaki, 2014). Inherent in this

approach is the notion that any link between CU traits and empathy may vary based on context,

and that empathy is, at least in part, motivated by context. However, no studies have explored

CU traits within a motivational account of empathy, despite the fact that a motivational approach

could help to establish basic understanding of the development of CU traits and inform potential

of
treatment targets. For example, CU traits could occur downstream of a bidirectional cascade

ro
whereby a lack of empathic arousal early in development results in children selecting themselves

-p
out of empathy-inducing situations, in turn reducing the practice children get at interpreting and
re
responding to social cues of distress (Zaki, 2014). Future research should examine the extent to

which the associations between CU traits and empathy vary by motivational context and how this
lP

influences specific cognitive and affective empathy deficits.

na

In relation to empathic arousal, it is also worth considering the role of “unemotionality”

within CU traits, the origins of which can be found in the PCL-R, which includes the item
ur

“shallow affect”. There continues to be debate in the literature about the importance of
Jo

“unemotionality” to theoretical conceptualizations of CU traits. It has been argued that whereas

youth high on CU traits are “unemotional” in response to others’ distress (i.e., low empathic

arousal or concern), they exhibit strong and wide-ranging emotions in other contexts, including

showing anger when their goals are frustrated or joy after breaking the rules and getting away

with it (Lahey, 2014; Salekin, Andershed, Batky, & Bontemps, 2018). Current measures for

assessing unemotionality, notably the unemotional items within the ICU, may not be capable of

capturing the distinction between these different forms of emotional expression. Based on the
 Journal Pre-proof

findings of this review, measurement might be enhanced by specifically augmenting measures of

CU traits with items that more directly assess empathic arousal (cf., the Bryant Empathy Index).

Moreover, perhaps even the term “unemotional” may need revising, because it does not truly

capture the nature of the deficit as related to CU traits, even if the sentiment is warranted.

Instead, the phrase “lack of emotional sensitivity” may more accurately characterize the

unemotional portion of the construct of CU traits, which ties back into empathic arousal.

Guilt and CU traits

of
Our final construct of interest was guilt. We found a moderate effect size for the

ro
association between CU traits and guilt, albeit based on only four studies. While the moderate

-p
association observed in the current study is largely consistent with hypotheses, the small number
re
of effect sizes included our review make it challenging to draw strong conclusions. Indeed, it is

surprising that there were so few studies that had directly examined links between CU traits and
lP

guilt given the many explicit references to guilt and remorse in measures of CU traits, including
na

the ICU and DSM-5 diagnostic criteria. Moreover, the developmental literature on guilt

highlights its importance for promoting and eliciting cooperation and prosocial behavior from
ur

ages 2-3 years old (Vaish, 2018). Thus, early deficits in the development of guilt, or early signs
Jo

that guilt development has gone awry may signal risk for children developing CU traits.

Semantics Issues that Impact Substantive Interpretations

Beyond the actual content of items, a final point relating to definitions of CU traits within

studies included in this review centers on the semantic structure of items. Some items assessing

CU traits are “positively” written (i.e., higher scores equate to higher CU traits), such that they

indicate the presence of callousness with words that are specifically synonyms for callous

behavior: “I seem very cold and uncaring to others” or “I hide my feelings from others.” Other
 Journal Pre-proof

positively written items are created by adding words like “not” or “no” or morphemes like “un-”

and “-less” to items assessing antonyms of callousness, for example: “I do not feel remorseful

when I do something wrong. Other items assessing CU traits are “negatively” written (i.e., lower

scores equate to higher CU traits). These negative items are reversed to reduce the effects of

response style, social desirability, and item difficulty that might plague positive items (i.e., that it

is more “difficult” to rate for the presence of traits that are perceived to have negative social

connotations). Specifically, items are used that will ultimately have the opposite meaning, for

of
example “I am very expressive and emotional”, is then “reverse-score” to index CU traits

ro
(“negatively-worded”). However, both positively- and negatively-worded items are likely

-p
warranted in any measure of CU traits in light of item response theory (IRT) analysis suggesting
re
that positively-worded items are more likely to be rated in the lower response categories and

show higher difficulty levels (i.e., discriminate more among children with higher levels of CU
lP

traits) (Ray, Frick, Thornton, Steinberg, & Cauffman, 2016). Including both positively- and
na

negatively-worded items allows for scores to be generated across the full dimensional range for

CU traits from low-risk to severe (Ray & Frick, 2018). This scoring approach is important when
ur

integrating developmentally-informed research examining empathy, prosociality, and guilt in

Jo

typically developing children with clinically-informed research examining these processes

having gone awry in clinic-referred or incarcerated samples of children with antisocial behavior.

Moderation

Our exploration of factors that influence the strength of the relationship between CU traits

and empathy, prosociality, and guilt revealed very few examples of moderation. Neither gender

nor sample type emerged as moderators. That is, CU traits were associated with lower empathy,

guilt, and prosociality to the same degree for boys and girls and for clinic-referred/incarcerated
 Journal Pre-proof

samples and community samples. This finding is important in light of an earlier study suggesting

that items indexing the presence of callous and uncaring behaviors may be most discriminatory

among children with severe antisocial behavior, whereas items indexing empathy, prosociality,

and guilt (reverse-coded) may be more helpful in assessing less severe manifestations of the

construct (p. 400, Ray, et al., 2016). Our results suggest that the correlations between CU traits

and empathy, prosociality, and guilt are similar in children with varying levels of antisocial

behavior – that is the core correlates of CU traits are similar across the full spectrum of antisocial

of
behavior. The lack of significant moderation by gender that we found is also consistent with

ro
prior meta-analytic work suggesting that the presence of CU traits is related to greater antisocial

-p
behavior to the same degree in males and females in early childhood (Longman, et al., 2016).
re
We did find evidence for moderation in relation to associations between CU traits and

cognitive versus affective empathy. There was a stronger association between lower cognitive
lP

empathy and CU traits at younger ages. In addition, the relative magnitude of the association
na

between CU traits and affective versus cognitive empathy was moderated by age (i.e., the extent

to which CU traits were more strongly related to affective or cognitive empathy deficits).
ur

Specifically, CU traits were more strongly related to cognitive than affective empathy younger
Jo

samples, whereas CU traits were more strongly related to lower affective empathy than cognitive

empathy in older samples. One interpretation of these findings is that the stronger relationship

we found between cognitive empathy deficits and CU traits at younger ages disappears over time

as children “acquire” or develop cognitive empathy, perhaps due to intact skills in other

cognitive processing domains, such as perspective-taking (cf., "learning to talk the talk"; Dadds,

et al., 2009). Notably however, we found moderation of the association between CU traits and

lower cognitive empathy based on informant, such that the association was stronger when the
 Journal Pre-proof

informant was a parent or teacher. Unfortunately, the independence of the age-informant effects

are challenging to disentangle as sample age and the informant being someone other than the

child were almost entirely confounded. In all samples that examined cognitive empathy where

the mean age was < 8 years old (n=6), the informant for CU traits and cognitive empathy was a

parent or teacher. When the younger samples were removed from the analysis, the effect of the

informant being a parent or teacher on the magnitude of the relationship between lower cognitive

empathy and CU traits was no longer significant. This finding implies that the informant effect

of
may have been driven by age rather than representing a true method effect. However, in 56 of the

ro
59 studies (95%) the informant for the CU traits measure and the outcome measure was also the

-p
same, meaning we were unable to formally test whether there was moderation based on cross-
re
versus within-informant associations. Our results clearly highlight the need for future studies that

include multi-informant and multi-method approaches for assessing prosociality, empathy, and
lP

guilt to establish whether there are meaningful developmental versus methodological effects on
na

the relationship between CU traits and cognitive empathy.

Limitations
ur

The findings of the current systematic and meta-analytic review should be

Jo

considered alongside several important limitations. First, we highlight the somewhat forced

separation we imposed on the constructs of empathy, prosociality, and guilt, by exploring their

links with CU traits in separate meta-analyses. That is, we know from developmental

psychopathology that all three of these socioemotional processes are inter-related (Eisenberg, et

al., 2015). Thus, a more complete meta-analytic model of the core defining features of CU traits

would be to consider associations with empathy, prosociality, and guilt in a single model. Indeed,

in the Introduction, we quoted the idea that “Occam's razor indicates that we should not think
 Journal Pre-proof

behavior to be complicated if we can make it simple by re-expressing, or reformulating, our

variables” (p. 86, Tukey, 1969). The moderate associations we found for the individual

associations between CU traits and empathy, prosociality, and guilt (i.e., <.70) do not provide

support for the idea that CU traits represent simply a re-expressing or re-formulation of these

other constructs when they are considered in isolation. However, this point does not preclude the

possibility that CU traits can most parsimoniously be conceptualized as representing some joint

abstraction or the shared variance between low empathy, prosociality, and guilt. However, as

of
none of the included studies had examined all three in relation to CU traits, it was not possible to

ro
conduct the type of regression-based meta-analysis capable of assessing the unique contributions

-p
of empathy, prosociality, and guilt to generate an overall estimate for the variance that all three
re
jointly explain in CU traits. Likewise, in relation to the overall utility of the CU traits construct

as a predictor of risk for antisocial behavior, it is noteworthy that no prior studies have tested the
lP

predictive validity of CU traits over and above knowing about low empathy, guilt, and
na

prosociality. Such an approach would further help to inform our knowledge of the uniqueness of

the construct and the value of knowing about CU traits as a joint abstraction of low empathy,
ur

guilt, and prosociality in relation to risk for antisocial behavior or psychopathy.

Jo

Second, although we consider CU traits to be central for understanding risk for antisocial

behavior and psychopathy across development, they cannot be considered in isolation. Indeed,

psychopathy and antisocial behavior are characterized by a highly complex and sometimes

counterintuitive combination of behavioral and personality deficits. To that end, we agree with

the conclusions of several recent reports that a more complete and broad model of antisocial

behavior development needs to take into account the interaction of CU traits with other

childhood precursors of psychopathy, including impulsivity, grandiosity, manipulativeness, and

 Journal Pre-proof

narcissism (Andershed, et al., 2018; Salekin, et al., 2018). Traditionally, these constructs have

been studied less extensively in relation to risk for antisocial behavior because CU traits were

shown to exhibit strong predictive validity in relation to severe, chronic, and violent patterns of

offending within antisocial youth (Frick, et al., 1994; Frick, et al., 2014b). However, it will be

important for future studies to examine whether narcissism or impulsivity, constructs that are

also assessed via subscales within measures of childhood psychopathy, including the ASPD and

YPI (Andershed, Gustafson, Kerr, & Stattin, 2002; Frick & Hare, 2001; Salekin, et al., 2018),

of
exhibit distinct nomological networks relative to CU traits, which would provide further

ro
evidence for the construct and divergent validity of CU traits.

-p
Third, this type of conceptual, theory-driven meta-analysis can only ever be “as good as

what is put in.” While our decision to explore links between CU traits and prosociality, empathy,
re
and guilt was theory driven, other constructs and socioemotional characteristics are also known
lP

to correlate with CU traits. For example, the low-fear hypothesis purports that psychopathy is
na

underpinned by a fundamental deficit in fearfulness (Lykken, 1957) and developmental theory

has posited that temperamental fearlessness is a precursor to the development of CU traits or

ur

deficits in conscience, empathy, and guilt (Kochanska, 1997; Waller, et al., 2016b). Specifically,
Jo

fearlessness in infancy is thought to result in reduced sensitivity to others' distress and

punishment, leading to reduced learning about the outcomes of harmful behavior, and reduced

sensitivity to punishment/lack of guilt over wrong doing, thus increasing risk for CU traits

(Waller, et al., 2016b). In the case of this meta-analysis, we judged fearlessness to be central to

the development of CU traits, meaning it should be defined as a precursor, rather than a cross-

sectional correlate of CU traits; thus, we did not include fearlessness. However, future studies

could explore whether incorporating fearlessness into definitions, theoretical frameworks, and
 Journal Pre-proof

measures of CU traits improves our understanding of the construct and its predictive validity in

relation to antisocial behavior. At the same time, this approach may need to be balanced by a

continued focus on separating etiological factors or variables in the nomological network of CU

traits from what should be considered a defining or core feature of CU traits.

Finally, the current findings should also be considered alongside the need for, and the

potential impact of, correction for attenuation. Correction for attenuation is considered necessary

to address internal consistency biases due to measurement error. Poor reliability among measures

of
of CU traits, which could indicate heterogeneous item distributions or the presence of “random

ro
noise” in the data, might have operated to reduce the overall strength of correlations between

-p
measures. A number of articles (n=17) reported internal consistency below that .70 value, which
re
is typically considered an acceptable threshold (Nunnally & Bernstein, 1994), suggesting that

30−50% of total score variance could be attributable to non-systematic error. Not surprisingly,
lP

the estimates we obtained for correlations between CU traits, empathy, guilt, and prosociality
na

without correction for attenuation were lower, with effect sizes in the modest-to-moderate range

(Table 2 and Figure 2). However, given the frequent occurrence of low reliabilities among
ur

measures of CU traits, correction for attenuation was warranted to allow for a more accurate
Jo

exploration of the relationships of CU traits with measures of empathy, guilt, and prosociality.

Overall, while the results may represent an overestimation of the true magnitude of the effects,

confidence intervals for the corrected and uncorrected versions of estimates were largely

overlapping, increasing confidence in the findings and, at the most basic level, meta-analytic

results using uncorrected data still yielded significant and, at least moderate, associations

between constructs. The moderate-to-strong correlations reported in this review imply that future

measures of CU traits may be augmented, and made more reliable, by integrating traditional
 Journal Pre-proof

items tapping empathy, guilt, and prosociality.

Conclusions
The current meta-analytic review reports moderate-to-large effect sizes between CU traits

and low empathy, guilt, and prosociality. Thus, CU traits represent a multidimensional construct

encapsulating the presence of callous (i.e., low empathy), uncaring (low prosociality), and

remorseless (low guilt) behaviors. We established that the correlations of CU traits with

empathy, guilt, and prosociality were largely invariant across age, sex, type of measurement, and

of
severity of antisocial behavior, an important test of the generalizability and meaning of the CU

ro
traits construct across settings, developmental stages, and sample types. In contrast to

-p
predictions, there was no significant difference in the correlation of measures of CU traits and

measures of cognitive versus affective empathy. However, future studies that focus on isolating
re
perspective-taking skills could be informative for improving understanding of the sociocognitive
lP

profile of children with CU traits. Finally, while we focused on behavioral and questionnaire-
na

based assessments of our core constructs, future studies are needed to identify the unique

underlying mechanisms manifest in the behavioral outcome of CU traits, including via

ur

neuroimaging, observational and coding paradigms, and other, novel experimental tasks. Our
Jo

findings and conclusions thus cement the need for continued collaborations between clinicians,

developmental scientists, and neuroscientists to continue to build our knowledge of both CU

traits and expected individual differences in empathy, prosociality, and guilt across development.
 Journal Pre-proof

References

Aitken, M., Henry, S., & Andrade, B.F. (2018). Distilling heterogeneity among children with disruptive

behavior: associations between symptom patterns and social functioning. Journal of Abnormal

Child Psychology, 46, 1241-52.

Anastassiou-Hadjicharalambous, X., & Warden, D. (2008). Physiologically-indexed and self-perceived

affective empathy in conduct-disordered children high and low on callous-unemotional traits.

Child psychiatry and human development, 39, 503.

of
Andershed, H., Colins, O.F., Salekin, R.T., Lordos, A., Kyranides, M.N., & Fanti, K.A. (2018). Callous-

unemotional traits only versus the multidimensional psychopathy construct as predictors of

ro
various antisocial outcomes during early adolescence. Journal of Psychopathology and

Behavioral Assessment, 40, 16-25. -p

re
Andershed, H., Gustafson, S.B., Kerr, M., & Stattin, H. (2002). The usefulness of self‐reported

psychopathy‐like traits in the study of antisocial behaviour among non‐referred adolescents.

lP

European Journal of Personality, 16, 383-402.

na

Andershed, H., Hodgins, S., & Tengström, A. (2007). Convergent validity of the youth psychopathic

traits inventory (YPI) association with the psychopathy checklist: youth version (PCL: YV).
ur

Assessment, 14, 144-54.

Jo

Andrade, B.F., & Wade, M. (2016). Latent profiles of externalizing psychopathology and their relation to

children's aggression and social behavior. Journal of Developmental & Behavioral Pediatrics, 37,

442-50.

Angold, A., & Egger, H.L. (2007). Preschool psychopathology: lessons for the lifespan. Journal of Child

Psychology and Psychiatry, 48, 961-66.

Antoniadou, N., Kokkinos, C.M., & Markos, A. (2016). Possible common correlates between bullying

and cyber-bullying among adolescents. Psicología Educativa, 22, 27-38.

Association, A.P. (1980). Diagnostic and statistical manual (DSM-III). Washington, DC: American

Psychiatric Association.
 Journal Pre-proof

Barry, C.T., Frick, P.J., DeShazo, T.M., McCoy, M., Ellis, M., & Loney, B.R. (2000). The importance of

callous–unemotional traits for extending the concept of psychopathy to children. Journal of

abnormal psychology, 109, 335.

Baumeister, R.F., Stillwell, A.M., & Heatherton, T.F. (1994). Guilt: an interpersonal approach.

Psychological bulletin, 115, 243-67.

Berkout, O.V., Young, J.N., & Gross, A.M. (2011). Mean girls and bad boys: Recent research on gender

differences in conduct disorder. Aggression and violent behavior, 16, 503-11.

Borenstein, M., Hedges, L.V., Higgins, J., & Rothstein, H.R. (2010). A basic introduction to fixed‐effect

of
and random‐effects models for meta‐analysis. Research synthesis methods, 1, 97-111.

ro
Brouns, B.H., de Wied, M.A., Keijsers, L., Branje, S., van Goozen, S.H., & Meeus, W.H. (2013).

-p
Concurrent and prospective effects of psychopathic traits on affective and cognitive empathy in a
re
community sample of late adolescents. Journal of Child Psychology and Psychiatry, 54, 969-76.

Brownell, C.A. (2013). Early development of prosocial behavior: Current perspectives. Infancy, 18, 1-9.
lP

Bryant, B.K. (1982). An index of empathy for children and adolescents. Child development, 53, 413-25.
na

Chabrol, H., van Leeuwen, N., Rodgers, R.F., & Gibbs, J.C. (2011). Relations between self-serving

cognitive distortions, psychopathic traits, and antisocial behavior in a non-clinical sample of

ur

adolescents. Personality and Individual Differences, 51, 887-92.

Jo

Christian, R.E., Frick, P.J., Hill, N.L., Tyler, L., & Frazer, D.R. (1997). Psychopathy and conduct

problems in children: II. Implications for subtyping children with conduct problems. Journal of

the American Academy of Child & Adolescent Psychiatry, 36, 233-41.

Ciucci, E., & Baroncelli, A. (2014). The emotional core of bullying: Further evidences of the role of

callous–unemotional traits and empathy. Personality and Individual Differences, 67, 69-74.

Colman, I., Murray, J., Abbott, R.A., Maughan, B., Kuh, D., Croudace, T.J., & Jones, P.B. (2009).

Outcomes of conduct problems in adolescence: 40 year follow-up of national cohort. British

Medical Journal, 338.

Crapanzano, A.M., Frick, P.J., Childs, K., & Terranova, A.M. (2011). Gender differences in the
 Journal Pre-proof

assessment, stability, and correlates to bullying roles in middle school children. Behavioral

Sciences & the Law, 29, 677-94.

Crick, N.R., Murray-Close, D., & Woods, K. (2005). Borderline personality features in childhood: A

short-term longitudinal study. Development and Psychopathology, 17, 1051-70.

Dadds, M.R., Allen, J.L., McGregor, K., Woolgar, M., Viding, E., & Scott, S. (2014). Callous‐

unemotional traits in children and mechanisms of impaired eye contact during expressions of

love: A treatment target? Journal of Child Psychology and Psychiatry, 55, 771-80.

of
Dadds, M.R., Cauchi, A.J., Wimalaweera, S., Hawes, D.J., & Brennan, J. (2012). Outcomes, moderators,

and mediators of empathic-emotion recognition training for complex conduct problems in

ro
childhood. Psychiatry research, 199, 201-07.

-p
Dadds, M.R., Hawes, D.J., Frost, A.D., Vassallo, S., Bunn, P., Hunter, K., & Merz, S. (2009). Learning to
re
‘talk the talk’: The relationship of psychopathic traits to deficits in empathy across childhood.

Journal of Child Psychology and Psychiatry, 50, 599-606.

lP

Davidov, M., Zahn‐Waxler, C., Roth‐Hanania, R., & Knafo, A. (2013). Concern for others in the first
na

year of life: Theory, evidence, and avenues for research. Child Development Perspectives, 7, 126-

31.
ur

Decety, J., & Lamm, C. (2006). Human empathy through the lens of social neuroscience. The scientific
Jo

World journal, 6, 1146-63.

Dolan, M.C., & Rennie, C.E. (2007). The relationship between psychopathic traits measured by the Youth

Psychopathic trait Inventory and psychopathology in a UK sample of conduct disordered boys.

Journal of adolescence, 30, 601-11.

Eisenberg, N., Spinrad, T.L., & Knafo-Noam, A. (2015). Prosocial development. In M.E. Lamb, C.

Garcia Coll & R.M. Lerner (Eds.), Handbook of Child Psychology, Vol. 3, Social, emotional, and

personality development (7th ed) (pp. 610-56). New York: NYC: Wiley.

Essau, C.A., Sasagawa, S., & Frick, P.J. (2006). Callous-unemotional traits in a community sample of

adolescents. Assessment, 13, 454-69.

 Journal Pre-proof

Ferguson, T.J., Stegge, H., Miller, E.R., & Olsen, M.E. (1999). Guilt, shame, and symptoms in children.

Developmental Psychology, 35, 347-57.

Findlay, L., Girardi, A., & Coplan, R. (2006). Links between empathy, social behavior, and social

understanding in early childhood. Early Childhood Research Quarterly, 21, 347-59.

Flight, J.I., & Forth, A.E. (2007). Instrumentally violent youths: The roles of psychopathic traits,

empathy, and attachment. Criminal justice and behavior, 34, 739-51.

Foulkes, L., Neumann, C.S., Roberts, R., McCrory, E., & Viding, E. (2017). Social Reward

of
Questionnaire—Adolescent Version and its association with callous–unemotional traits. Royal

Society open science, 4, 160991.

ro
Frick, P.J. (2004). The Inventory of Callous-Unemotional Traits. Unpublished rating scale.

-p
Frick, P.J. (2013). Clinical Assessment of Prosocial Emotions: Version 1.1 (CAPE 1.1) Unpublished
re
clinical rating manual.

Frick, P.J. (2016). Early identification and treatment of antisocial behavior. Pediatric Clinics, 63, 861-71.
lP

Frick, P.J., & Hare, R.D. (2001). Antisocial process screening device: APSD: Multi-Health Systems
na

Toronto.

Frick, P.J., O'Brien, B.S., Wootton, J.M., & McBurnett, K. (1994). Psychopathy and conduct problems in
ur

children. Journal of abnormal psychology, 103, 700.

Jo

Frick, P.J., Ray, J.V., Thornton, L.C., & Kahn, R.E. (2014a). Annual Research Review: A developmental

psychopathology approach to understanding callous-unemotional traits in children and

adolescents with serious conduct problems. Journal of Child Psychology and Psychiatry, 55, 532-

48.

Frick, P.J., Ray, J.V., Thornton, L.C., & Kahn, R.E. (2014b). Can callous-unemotional traits enhance the

understanding, diagnosis, and treatment of serious conduct problems in children and adolescents?

A comprehensive review. Psychological bulletin, 140, 1-57.

Frick, P.J., & White, S.F. (2008). Research review: The importance of callous‐unemotional traits for

developmental models of aggressive and antisocial behavior. Journal of Child Psychology and
 Journal Pre-proof

Psychiatry, 49, 359-75.

Georgiou, G., Kimonis, E.R., & Fanti, K.A. (2018). What do others feel? Cognitive empathy deficits

explain the association between callous-unemotional traits and conduct problems among

preschool children. European Journal of Developmental Psychology, 1-21.

Gillen, C.T.A., Lee, Z., Salekin, K.L., Iselin, A.-M.R., Harrison, N.A., Clark, A.P., Colins, O.F., &

Salekin, R.T. (2018). Psychopathic traits in adolescence: The importance of examining

components in face processing, voice processing, and emotional skill. Journal of

of
Psychopathology and Behavioral Assessment, 40, 50-59.

Gostisha, A.J., Vitacco, M.J., Dismukes, A.R., Brieman, C., Merz, J., & Shirtcliff, E.A. (2014). Beyond

ro
physiological hypoarousal: The role of life stress and callous-unemotional traits in incarcerated

-p
adolescent males. Hormones and behavior, 65, 469-79.
re
Hare, R.D. (1999). Without conscience: The disturbing world of the psychopaths among us: Guilford

Press.
lP

Hare, R.D., & Neumann, C.S. (2008). Psychopathy as a clinical and empirical construct. Annual review of
na

psychology, 4, 217-46.

Hawes, D., & Dadds, M.R. (2005). The treatment of conduct problems in children with callous-
ur

unemotional traits. Journal of Consulting and Clinical Psychology, 73, 737-41.

Jo

Hawes, D.J., & Dadds, M.R. (2007). Stability and Malleability of Callous-Unemotional Traits During

Treatment for Childhood Conduct Problems. Journal of Clinical Child & Adolescent Psychology,

36, 347-55.

Hawes, S.W., Byrd, A.L., Henderson, C.E., Gazda, R.L., Burke, J.D., Loeber, R., & Pardini, D.A. (2014).

Refining the parent-reported Inventory of Callous–Unemotional Traits in boys with conduct

problems. Psychological assessment, 26, 256.

Hein, G., & Singer, T. (2008). I feel how you feel but not always: the empathic brain and its modulation.

Current opinion in neurobiology, 18, 153-58.

Hoffman, M.L. (1977). Sex differences in empathy and related behaviors. Psychological bulletin, 84, 712.
 Journal Pre-proof

Högström, J., Enebrink, P., & Ghaderi, A. (2013). The moderating role of child callous-unemotional traits

in an Internet-based parent-management training program. Journal of Family Psychology, 27,

314-23.

Holmqvist, R. (2008). Psychopathy and Affect Consciousness in Young Criminal Offenders. Journal of

Interpersonal Violence, 23, 209-24.

Jolliffe, D., & Farrington, D.P. (2004). Empathy and offending: A systematic review and meta-analysis.

Aggression and violent behavior, 9, 441-76.

of
Jones, A.P., Happé, F.G., Gilbert, F., Burnett, S., & Viding, E. (2010). Feeling, caring, knowing: different

types of empathy deficit in boys with psychopathic tendencies and autism spectrum disorder.

ro
Journal of Child Psychology and Psychiatry, 51, 1188-97.

-p
Kahn, R.E., Frick, P.J., Golmaryami, F.N., & Marsee, M.A. (2017). The Moderating Role of Anxiety in
re
the Associations of Callous-Unemotional Traits with Self-Report and Laboratory Measures of

Affective and Cognitive Empathy. Journal of Abnormal Child Psychology, 45, 583-96.
lP

Kimonis, E.R., Fanti, K.A., Anastassiou-Hadjicharalambous, X., Mertan, B., Goulter, N., & Katsimicha,
na

E. (2016). Can callous-unemotional traits be reliably measured in preschoolers? Journal of

Abnormal Child Psychology, 44, 625-38.

ur

Kimonis, E.R., Frick, P.J., Skeem, J.L., Marsee, M.A., Cruise, K., Munoz, L.C., Aucoin, K.J., & Morris,
Jo

A.S. (2008). Assessing callous–unemotional traits in adolescent offenders: Validation of the

Inventory of Callous–Unemotional Traits. International Journal of Law and Psychiatry, 31, 241-

52.

Kochanska, G. (1997). Multiple pathways to conscience for children with different temperaments: from

toddlerhood to age 5. Developmental Psychology, 33, 228-40.

Kochanska, G., Gross, J.N., Lin, M.H., & Nichols, K.E. (2002). Guilt in young children: Development,

determinants, and relations with a broader system of standards. Child development, 73, 461-82.

Kongerslev, M.T., Bo, S., Forth, A.E., & Simonsen, E. (2015). Assessment of the affective dimensions of

psychopathy with the Danish version of the Inventory of Callous-Unemotional Traits among
 Journal Pre-proof

incarcerated boys: a study of reliability, criterion validity, and construct validity. Scandinavian

Journal of Child and Adolescent Psychiatry and Psychology, 3, 80-96.

Lahey, B.B. (2014). What we need to know about callous-unemotional traits: comment on Frick, Ray,

Thornton, and Kahn (2014). Psychological bulletin, 140, 58-63.

Lipsey, M.W., & Wilson, D.B. (2001). Practical meta-analysis: Sage Publications, Inc.

Liu, J., Qiao, X., Dong, F., & Raine, A. (2018). The Chinese version of the cognitive, affective, and

somatic empathy scale for children: Validation, gender invariance and associated factors. PloS

of
one, 13, e0195268.

Longman, T., Hawes, D.J., & Kohlhoff, J. (2016). Callous–unemotional traits as markers for conduct

ro
problem severity in early childhood: a meta-analysis. Child Psychiatry & Human Development,

47, 326-34.
-p
re
López-Romero, L., Gómez-Fraguela, J.A., & Romero, E. (2015). Assessing Callous-Unemotional Traits

in a Spanish Sample of Institutionalized Youths: The Inventory of Callous-Unemotional Traits.

lP

Journal of Psychopathology and Behavioral Assessment, 37, 392-406.

na

López-Romero, L., Molinuevo, B., Bonillo, A., Andershed, H., Colins, O.F., Torrubia, R., & Romero, E.

(2018). Psychometric properties of the Spanish version of the Child Problematic Traits Inventory
ur

in 3- to 12-year-old Spanish children. European Journal of Psychological Assessment, No

Jo

Pagination Specified-No Pagination Specified.

López-Romero, L., Romero, E., & Andershed, H. (2015). Conduct Problems in Childhood and

Adolescence: Developmental Trajectories, Predictors and Outcomes in a Six-Year Follow Up.

Child Psychiatry & Human Development, 46, 762-73.

Lotze, G.M., Ravindran, N., & Myers, B.J. (2010). Moral Emotions, Emotion Self-Regulation, Callous-

Unemotional Traits, and Problem Behavior in Children of Incarcerated Mothers. Journal of Child

and Family Studies, 19, 702-13.

Lui, J.H.L., Barry, C.T., & Sacco, D.F. (2016). Callous-unemotional traits and empathy deficits:

Mediating effects of affective perspective-taking and facial emotion recognition. Cognition and
 Journal Pre-proof

Emotion, 30, 1049-62.

Lykken, D.T. (1957). A study of anxiety in the sociopathic personality. The Journal of Abnormal and

Social Psychology, 55, 6-10.

Malcolm-Smith, S., Woolley, D., & Ward, C.L. (2015). Examining empathy and its association with

aggression in young Western Cape children. Journal of Child & Adolescent Mental Health, 27,

135-47.

Martin-Key, N., Brown, T., & Fairchild, G. (2017). Empathic Accuracy in Male Adolescents with

of
Conduct Disorder and Higher versus Lower Levels of Callous-Unemotional Traits. Journal of

Abnormal Child Psychology, 45, 1385-97.

ro
McDonald, S.E., Ma, L., Green, K.E., Hitti, S.A., Cody, A.M., Donovan, C., Williams, J.H., & Ascione,

-p
F.R. (2018). Evaluation of the Parent-Report Inventory of Callous–Unemotional Traits in a
re
Sample of Children Recruited from Intimate Partner Violence Services: A Multidimensional

Rasch Analysis. Journal of Clinical Psychology, 74, 418-41.

lP

Meehan, A.J., Maughan, B., Cecil, C.A.M., & Barker, E.D. (2017). Interpersonal callousness and co-
na

occurring anxiety: Developmental validity of an adolescent taxonomy. Journal of abnormal

psychology, 126, 225-36.

ur

Meltzer, H., Gatward, R., Goodman, R., & Ford, T. (2000). The mental health of children and adolescents
Jo

in Great Britain: HM Stationery Office.

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

F., & Muratori, P. (2019). Empathy in Youths with Conduct Disorder and Callous-Unemotional

Traits. Neural Plasticity, 2019, 8.

Moffitt, T.E., Caspi, A., Harrington, H., & Milne, B.J. (2002). Males on the life-course-persistent and

adolescence-limited antisocial pathways: Follow-up at age 26 years. Development and

Psychopathology, 14, 179-207.

Morris, R., Bramham, J., Smith, E., & Tchanturia, K. (2014). Empathy and social functioning in anorexia

nervosa before and after recovery. Cognitive neuropsychiatry, 19, 47-57.

 Journal Pre-proof

Muñoz, L.C., Qualter, P., & Padgett, G. (2011). Empathy and Bullying: Exploring the Influence of

Callous-Unemotional Traits. Child Psychiatry & Human Development, 42, 183-96.

Nelissen, R., & Zeelenberg, M. (2009). When guilt evokes self-punishment: evidence for the existence of

a Dobby Effect. Emotion, 9, 118-22.

Neumann, C.S., Hare, R.D., & Pardini, D.A. (2015). Antisociality and the construct of psychopathy: Data

from across the globe. Journal of Personality, 83, 678-92.

Nunnally, J.C., & Bernstein, I. (1994). Psychometric Theory (McGraw-Hill Series in Psychology) (Vol.

of
3): McGraw-Hill New York.

O’Kearney, R., Salmon, K., Liwag, M., Fortune, C.-A., & Dawel, A. (2017). Emotional Abilities in

ro
Children with Oppositional Defiant Disorder (ODD): Impairments in Perspective-Taking and

-p
Understanding Mixed Emotions are Associated with High Callous–Unemotional Traits. Child
re
Psychiatry & Human Development, 48, 346-57.

Pardini, D., Obradovic, J., & Loeber, R. (2006). Interpersonal callousness, hyperactivity/impulsivity,
lP

inattention, and conduct problems as precursors to delinquency persistence in boys: A

na

comparison of three grade-based cohorts. Journal of clinical child and adolescent psychology, 35,

46-59.
ur

Pardini, D.A., Lochman, J.E., & Frick, P.J. (2003). Callous/Unemotional Traits and Social-Cognitive
Jo

Processes in Adjudicated Youths. Journal of the American Academy of Child & Adolescent

Psychiatry, 42, 364-71.

Pasalich, D.S., Dadds, M.R., & Hawes, D.J. (2014). Cognitive and affective empathy in children with

conduct problems: Additive and interactive effects of callous–unemotional traits and autism

spectrum disorders symptoms. Psychiatry research, 219, 625-30.

Pechorro, P., Hawes, S.W., Gonçalves, R.A., & Ray, J.V. (2017). Psychometric properties of the

inventory of callous-unemotional traits short version (ICU-12) among detained female juvenile

offenders and community youths. Psychology, Crime & Law, 23, 221-39.

Pechorro, P., Hidalgo, V., Nunes, C., & Jiménez, L. (2016). Confirmatory Factor Analysis of the
 Journal Pre-proof

Antisocial Process Screening Device:Self-Report Among Incarcerated Male Juvenile Offenders.

International journal of offender therapy and comparative criminology, 60, 1856-72.

Pechorro, P., Jiménez, L., Hidalgo, V., & Nunes, C. (2015). The DSM-5 Limited Prosocial Emotions

subtype of Conduct Disorder in incarcerated male and female juvenile delinquents. International

Journal of Law and Psychiatry, 39, 77-82.

Pechorro, P., Ray, J.V., Salas-Wright, C.P., Maroco, J., & Gonçalves, R.A. (2015). Adaptation of the

Basic Empathy Scale among a Portuguese sample of incarcerated juvenile offenders. Psychology,

of
Crime & Law, 21, 699-714.

Pechorro, P.S., Vieira, D.N., Poiares, C.A., Vieira, R.X., Marôco, J., Neves, S., & Nunes, C. (2013).

ro
Psychopathy and behavior problems: A comparison of incarcerated male and female juvenile

-p
delinquents. International Journal of Law and Psychiatry, 36, 18-22.
re
Pijper, J., de Wied, M., van Rijn, S., van Goozen, S., Swaab, H., & Meeus, W. (2016). Callous

unemotional traits, autism spectrum disorder symptoms and empathy in boys with oppositional
lP

defiant disorder or conduct disorder. Psychiatry research, 245, 340-45.

na

Quay, H.C. (1993). The psychobiology of undersocialized aggressive conduct disorder: A theoretical

perspective. Development and Psychopathology, 5, 165-80.

ur

Raine, A., & Chen, F.R. (2018). The Cognitive, Affective, and Somatic Empathy Scales (CASES) for
Jo

Children. Journal of Clinical Child & Adolescent Psychology, 47, 24-37.

Raine, A., & Yang, Y. (2006). Neural foundations to moral reasoning and antisocial behavior. Social

cognitive and affective neuroscience, 1, 203-13.

Ray, J.V., & Frick, P.J. (2018). Assessing Callous-Unemotional Traits Using the Total Score from the

Inventory of Callous-Unemotional Traits: A Meta-Analysis. Journal of Clinical Child &

Adolescent Psychology.

Ray, J.V., Frick, P.J., Thornton, L.C., Steinberg, L., & Cauffman, E. (2016). Positive and negative item

wording and its influence on the assessment of callous-unemotional traits. Psychological

assessment, 28, 394.

 Journal Pre-proof

Roose, A., Bijttebier, P., Decoene, S., Claes, L., & Frick, P.J. (2010). Assessing the Affective Features of

Psychopathy in Adolescence: A Further Validation of the Inventory of Callous and Unemotional

Traits. Assessment, 17, 44-57.

Salekin, R.T., Andershed, H., Batky, B.D., & Bontemps, A.P. (2018). Are Callous Unemotional (CU)

Traits Enough? Journal of Psychopathology and Behavioral Assessment, 1-5.

Schmidt, F.L., & Hunter, J.E. (2014). Methods of meta-analysis: Correcting error and bias in research

findings. Thousand Oaks, CA, USA: SAGE Publications, Inc.

of
Shamay-Tsoory, S.G., & Aharon-Peretz, J. (2007). Dissociable prefrontal networks for cognitive and

affective theory of mind: a lesion study. Neuropsychologia, 45, 3054-67.

ro
Sober, E., & Wilson, D.S. (1998). Unto Others Princeton University Press: Princeton, USA

-p
Spice, A., Viljoen, J.L., Douglas, K.S., & Hart, S.D. (2015). Remorse, psychopathology, and psychopathy
re
among adolescent offenders. Law and human behavior, 39, 451.

Stern, J., & Cassidy, J. (2018). Empathy from infancy to adolescence: An attachment perspective on the
lP

development of individual differences. Developmental Review, 47, 1-22.

na

Stickle, T.R., Marini, V.A., & Thomas, J.N. (2012). Gender Differences in Psychopathic Traits, Types,

and Correlates of Aggression Among Adjudicated Youth. Journal of Abnormal Child

ur

Psychology, 40, 513-25.

Jo

Tukey, J.W. (1969). Analyzing data: Sanctification or detective work? American Psychologist, 24, 83-91.

Vahl, P., Colins, O.F., Lodewijks, H.P.B., Markus, M.T., Doreleijers, T.A.H., & Vermeiren, R.R.J.M.

(2014). Psychopathic-like traits in detained adolescents: clinical usefulness of self-report.

European child & adolescent psychiatry, 23, 691-99.

Vaish, A. (2018). The prosocial functions of early social emotions: the case of guilt. Current Opinion in

Psychology, 20, 25-29.

van Baardewijk, Y., Stegge, H., Andershed, H., Thomaes, S., Scholte, E., & Vermeiren, R. (2008).

Measuring psychopathic traits in children through self-report. The development of the Youth

Psychopathic traits Inventory—Child Version. International Journal of Law and Psychiatry, 31,
 Journal Pre-proof

199-209.

van Buuren, S., & Groothuis-Oudshoorn, K. (2011). Mice: multivariate imputation by chained equations

in R. JStat Softw 45 (3): 1–67. In.

van Vugt, E.S., Asscher, J.J., Hendriks, J., Stams, G.J.J.M., Bijleveld, C.C.J.H., & van der Laan, P.H.

(2012). The relationship between psychopathy and moral development in young sex offenders.

Psychology, Crime & Law, 18, 655-67.

Verschuere, B., Candel, I., Van Reenen, L., & Korebrits, A. (2012). Validity of the Modified Child

of
Psychopathy Scale for juvenile justice center residents. Journal of Psychopathology and

Behavioral Assessment, 34, 244-52.

ro
Verschuere, B., van Ghesel Grothe, A.S., Waldorp, L., Watts, A., Edens, J.F., Skeem, J., & Noordhof, A.

-p
(2017). What Features of Psychopathy Might be Central? A Network Analysis of the
re
Psychopathy Checklist-Revised (PCL-R) in Three Large Samples. Journal of abnormal

psychology, 127, 51-65.

lP

Viding, E., Simmonds, E., Petrides, K.V., & Frederickson, N. (2009). The contribution of callous-
na

unemotional traits and conduct problems to bullying in early adolescence. Journal of Child

Psychology and Psychiatry, 50, 471-81.

ur

Viechtbauer, W. (2010). Conducting meta-analyses in R with the metafor package. Journal of Statistical
Jo

Software, 36, 1-48.

Waller, R., Dishion, T.J., Shaw, D.S., Gardner, F., Wilson, M., & Hyde, L.W. (2016a). Does early

childhood callous-unemotional behavior uniquely predict behavior problems or callous-

unemotional behavior in late childhood? Developmental Psychology, 52, 1805-19.

Waller, R., & Hyde, L.W. (2018). Callous-unemotional behaviors in early childhood: the development of

empathy and prosociality gone awry. Current Opinion in Psychology, 20, 11-16.

Waller, R., Hyde, L.W., Grabell, A.S., Alves, M.L., & Olson, S.L. (2015). Differential associations of

early callous unemotional, oppositional, and ADHD behaviors: multiple domains within early

starting conduct problems? Journal of Child Psychology and Psychiatry, 56, 657-66.
 Journal Pre-proof

Waller, R., Shaw, D.S., Neiderhiser, J.M., Ganiban, J.M., Natsuaki, M.N., Reiss, D., Trentacosta, C., J.,

Leve, L.D., & Hyde, L.W. (2017). Towards an understanding of the role of the environment in

the development of early callous behavior. Journal of Personality, 85, 90-103.

Waller, R., Trentacosta, C., Shaw, D.S., Neiderhiser, J.M., Ganiban, J., Reiss, D., Leve, L.D., & Hyde,

L.W. (2016b). Heritable temperament pathways to early callous-unemotional behavior. The

British Journal of Psychiatry, 209, 475-82.

Wendt, G.W., Bartoli, A.J., & Arteche, A. (2017). Dimensions of youth psychopathy differentially predict

of
concurrent pro- and antisocial behavior. Brazilian Journal of Psychiatry, 39, 267-70.

Whitt, A., & Howard, M.O. (2013). Assessing Empathy in Antisocial Youth: Factor Analytic and

ro
Validation Findings. Psychological reports, 112, 325-39.

-p
Willoughby, M.T., Mills-Koonce, W.R., Waschbusch, D.A., Gottfredson, N.C., & Investigators, F.L.P.
re
(2015). An examination of the parent report version of the inventory of callous-unemotional traits

in a community sample of first-grade children. Assessment, 22, 76-85.

lP

Zaki, J. (2014). Empathy: a motivated account. Psychological bulletin, 140, 1608.

na
ur
Jo
 Journal Pre-proof
Table 1. Characteristics of Included Studies
% CU traits CU traits Empathy Guilt Outcome
Citation Country N Mean age Type of sample Prosocial
female measure respondent measure measure respondent
1 Aitken, Henry, and Andrade (2018) Canada 304 9.25 33 Clinical IOWA Parent SDQ Parent
Anastassiou-Hadjicharalambous and Warden
2 Scotland 66 9.36 4.55 Clinical APSD Parent & Teacher BEI Self
(2008)
3 Andrade and Wade (2016) Canada 208 8.8 21.6 Clinical 3 ICU items Parent & Teacher SDQ Parent
4 Antoniadou, Kokkinos, and Markos (2016) Greece 146 14.5 43 Community YPI Self BES Self
16.8 (M)
5 Brouns, et al. (2013) Netherlands 233 54 Community APSD Parent IRI Self
16.61 (F)

f
Chabrol, van Leeuwen, Rodgers, and Gibbs
6 France 972 16.7 39 Community YPI Self IRI Self
(2011)
7
8
Ciucci and Baroncelli (2014)
Crapanzano, Frick, Childs, and Terranova (2011)
Italy
USA
529
284
12.7
11.28
53.3
54.2
Community
Community
ICU

o
APSD
o Self
Self
HIFDS
CSBS
Self
Self
9

10
Dadds, et al. (2009)
Dadds, Cauchi, Wimalaweera, Hawes, and
Australia

Australia
2760

195
7.79

10.52
49.8

24.4
Community

Clinical

p r
APSD & SDQ

APSD & SDQ

Parent

Parent & Teacher

GEM

GEM
Parent

Parent

-
Brennan (2012)
11 Dadds, et al. (2014) England 55 5.5 45.44 Clinical APSD & SDQ Parent SDQ Parent
12
13
Dolan and Rennie (2007)
Flight and Forth (2007)
England
Canada
115
51
16.2
17.1
0
0
r e
Incarcerated
Community
YPI
PCL:YC
Self
Self
IVE
IRI
Self
Self

14

15
Foulkes, Neumann, Roberts, McCrory, and
Viding (2017)
Georgiou, Kimonis, and Fanti (2018)
UK

Greece
558

167
12.89

4.73
l
50

49.1 PCommunity

Community
APSD

ICU
Self

Parent & Teacher GEM

Self

Parent
16 Gillen, et al. (2018) USA 144 15.24

a 34 Incarcerated PCL:YV Self IRI Self

rn
17 Gostisha, et al. (2014) USA 50 16.09 0 Incarcerated ICU Self IRI Self
18 Hawes and Dadds (2007) Australia 56 6.29 0 Clinical APSD & SDQ Parent SDQ Parent
19
20
Hawes, et al. (2014)
Högström, Enebrink, and Ghaderi (2013)
USA
Sweden

o u
150
57
8.99
6.65
0
45.6
Clinical
Community
ICU
APSD
Parent
Parent
SCS
SDQ
Parent
Parent
21
22
23
24
Holmqvist (2008)
Kahn, Frick, Golmaryami, and Marsee (2017)
Kimonis, et al. (2008)
Kimonis, et al. (2016)
Sweden
USA
USA
USA
J 47
107
248
214
17
15.5
15.47
4.7
0
0
24.2
46.7
Incarcerated
Community
Incarcerated
Community
PCL:SV
ICU
ICU
ICU
Interviewer
Self
Self
Parent & Teacher
EI
BES
EQI
GEM SDQ
HCR - 20 Self
Self
Self
Parent
25 Kongerslev, Bo, Forth, and Simonsen (2015) Denmark 80 16.5 0 Incarcerated ICU Self IRI Self
26 Liu, Qiao, Dong, and Raine (2018) China 860 11.54 47.9 Community ICU Self CASES Self
López-Romero, Gómez-Fraguela, and Romero
27 Spain 324 16.13 27.5 Incarcerated ICU Self BES Self
(2015)
28 López-Romero, Romero, and Andershed (2015) Spain 192 8.05 27.6 Community ICU Self BES Self
29 López-Romero, et al. (2018) Spain 449 7.43 51.4% Community APSD Teacher SDQ Teacher
TOSCA-
30 Lotze, Ravindran, and Myers (2010) USA 50 9.8 62 Community APSD Self Self
C
31 Lui, Barry, and Sacco (2016) USA 103 16.9 32 Incarcerated ICU Self GEM Self
 Journal Pre-proof
32 Malcolm-Smith, Woolley, and Ward (2015) South Africa 114 6.58 36.8 Community APSD & SDQ Parent GEM Parent
33 Martin-Key, Brown, and Fairchild (2017) UK 37 16.03 0 Incarcerated ICU Self IRI Self
34 McDonald, et al. (2018) USA 291 9.07 47 Community ICU Parent GEM Parent
35 Meehan, Maughan, Cecil, and Barker (2017) England 6791 13 51.11 Community IC measure Parent SDQ Parent
36 Milone, et al. (2019) Italy 60 13.27 0 Clinical APSD Parent & Self IRI Self
37 Muñoz, Qualter, and Padgett (2011) England 201 11.5 50 Community ICU Self BES Self
O’Kearney, Salmon, Liwag, Fortune, and Dawel
38 Australia 74 5.8 0 Community ICU Parent GEM Parent
(2017)
39 Pardini, Lochman, and Frick (2003) USA 169 15.8 42.6 Incarcerated APSD-SR Self IRI Self
40
41
Pasalich, Dadds, and Hawes (2014)
Pechorro, et al. (2013)
Australia
Portugal
134
261
5.6
15.8
21
16.8
Clinical
Incarcerated
APSD & SDQ
APSD-SR

o f
Parent & Teacher
Self
GEM
SDQ
Parent
Self

ro
Pechorro, Ray, Salas-Wright, Maroco, and
42 Portugal 221 16.75 0 Incarcerated APSD, ICU Self BES Self
Gonçalves (2015)
43 Pechorro, Jiménez, Hidalgo, and Nunes (2015) Portugal 299 15.89 32.7 Incarcerated APSD-SR Self SDQ-SR Self
44 Pechorro, Hidalgo, Nunes, and Jiménez (2016) Portugal 438 17.15 0

- p
Incarcerated
Incarcerated &
APSD-SR Self BES Self

e
45 Pechorro, Hawes, Gonçalves, and Ray (2017) Portugal 377 16.23 100 ICU Self BES Self
community

r
IECA &
46 Pijper, et al. (2016) Netherlands 49 10.28 0 Clinical APSD Parent & Teacher Self
BES
47

48
Raine and Chen (2018)
Roose, Bijttebier, Decoene, Claes, and Frick
(2010)
USA

Belgium
428

455
11

16.6

l
49

44
P Community

Community
ICU

ICU
Self
Self, Parent &
Teacher
CASES

IRI
Self

Self

a
TOSCA-
49 Spice, Viljoen, Douglas, and Hart (2015) Canada 97 15.88 29.9 Incarcerated PCL:YV Self Self
A

rn
50 Stickle, Marini, and Thomas (2012) USA 150 15.2 40 Incarcerated ICU Self & Teacher IRI Self
51 Vahl, et al. (2014) Netherlands 365 16.5 0 Incarcerated YPI-S Self SDQ Self
52
53
van Baardewijk, et al. (2008)
van Vugt, et al. (2012)
Netherlands
Netherlands

o u360
85
10.9
17.54
48
0
Community
Incarcerated
YPI-CV
APSD & ICU
Self
Self
BES
BES
Self
Self

J
Verschuere, Candel, Van Reenen, and Korebrits
54 Netherlands 57 16.75 0 Incarcerated CPS Self IRI Self
(2012)
Viding, Simmonds, Petrides, and Frederickson
55 England 704 12 47 Community ICU Self SDQ Self
(2009)
56 Waller, et al. (2015) USA 240 3.42 49.16 Community CBCL Parent My Child My Child Parent
57 Wendt, Bartoli, and Arteche (2017) England 249 10 53 Community APSD Self SDQ Self
58 Whitt and Howard (2013) USA 707 15.5 13.01 Clinical APSD Self PPI-SV Self
Willoughby, Mills-Koonce, Waschbusch,
59 USA 1078 7.3 50 Community ICU Parent SDQ Parent
Gottfredson, and Investigators (2015)
Note. M: Male; F: Female; APSD: Antisocial Process Screening Device – CU traits subscale; ICU: Inventory for Callous-Unemotional Traits; SDQ: Strengths and Difficulties Questionnaire; IC: Interpersonal Callousness;
YPI: Youth Psychopathic Traits Inventory; PPI-SV: Psychopathic Personality Inventory – Short Version; GEM: Griffith Empathy Measure; IRI: Interpersonal Reactivity Index; HIFDS: How I Feel in Different Situations;
BES: Basic Empathy Scale; CSBS: Children’s Social Behavior Scale; EQI: Emotion Quotient Inventory; SCS: Social Competence Scale; IVE: Impulsivity-Venturesomeness-Empathy Inventory; CUSD: Callous-Unemotional
Screening Device; TOSCA-C: Test of Self-Conscious Affect for Children; EI: Empathy Index; ICM: Interpersonal Callous Measure: HCR020: Historical Clinical Risk – 20; CASES: Cognitive Affective Somatic Empathy
Scale
 Journal Pre-proof
Table 2. Summary of findings from unconditional models comparing attenuation-corrected and
uncorrected effects

Outcome N k ρ CI95[LB, UB]

Empathy (Total) 10,252 36 -.57 (-.39) [-.67, -.47] ([-.44, -.34])
Prosociality 12,082 19 -.66 (-.49) [-.78, -.53] ([-..56, -.43])
Guilt 434 4 -.40 (-.28) [-.50, -.30] ([-.37, -.19])
Affective empathy (Subscale) 7,761 23 -.33 (-.25) [-.48, -.19] ([-.35, -.15])
Cognitive Empathy (Subscale) 8,733 24 -.44 (-.28) [-.52 -.33] ([-.34, -.22])
Affective vs. Cognitive 7,761 23 .07 (.22) [-.11, .25] ([.15, .29])
Note. Italicized text in parentheses present non-attenuation-corrected estimates – also see Figure 2

of
ro
-p
re
lP
na
ur
Jo
 Journal Pre-proof

Table 3. Estimates from models exploring moderation of the association between CU traits
and outcomes by gender, age, sample type, and informant
b t p
Total Empathy (df=34)
Proportion Female .17 .93 .36
Sample Age .00 .41 .69
Sample Type -.06 -.65 .52
CU Respondent -.08 -.73 .47
Outcome Respondent -.10 -.90 .38
ICU .07 .72 .48
Prosociality (df =17)
Proportion Female -.18 -.81 .43
Sample Age .03 1.69 .11

of
Sample Type .01 .13 .90
CU/Outcome Respondent .02 .13 .90

ro
ICU -.16 -1.32 .20
Affective Empathy (df =21)
Proportion Female .27 1.22 .24
Sample Age
Sample Type -p
-.02
-.08
-.94
-.51
.36
.62
re
CU Respondent .28 1.86 .08
Outcome Respondent .24 1.47 .16
ICU -.24 -1.66 .11
lP

Cognitive Empathy (df =22)

Proportion Female .03 .17 .86
Sample Age .03 2.55 .02
na

Sample Type -.09 -.8 .43

CU Respondent -.20 -1.8 .09
Outcome Respondent -.23 -2.44 .02
ur

ICU .04 .38 .71

Affective versus Cognitive Empathy Difference (df =21)
Jo

Proportion Female .19 .91 .38

Sample Age -.05 -3.14 .01
Sample Type .03 .19 .84
CU Respondent .47 4.12 < .001
Outcome Respondent .48 4.32 < .001
ICU -.31 -2.00 .06
Note. The tables presents estimates from moderation analysis examining whether gender, age, sample type,
informant, or measure moderated the association between CU traits and total empathy scores, affective empathy,
cognitive empathy, the relative difference between affective versus cognitive empathy, and prosociality. CU traits
were more strongly related to lower cognitive empathy in younger samples and when the informant was a
parent/teacher. Results are based on single variable moderator models in which each sample property of interest was
entered into separate models. Significant results identified above remained significant when all variables were
included in a simultaneous model, with the exception of respondent and age in the affective versus cognitive
empathy difference model, which were no longer significant when included in the same model. Note that for
prosociality, the informant for CU traits and prosociality was always the same (hence examined as a single
moderator).
 Journal Pre-proof

Figure 1. An escalating focus of research on callous-unemotional traits from the early 1990s
to the present day

of
ro
-p
re
lP
na
ur
Jo
 Journal Pre-proof

Figure 2. A comparison of the effect sizes for the main associations between CU traits and
empathy, prosociality, and guilt for attenuation corrected and non-corrected estimates.
CU traits and empathy

of
ro
-p
re
lP
na

CU traits and prosociality

ur
Jo

CU traits and guilt

Note. Attentuation Correction:

 Journal Pre-proof

Figure 3. Age moderated the relationship between CU traits and cognitive empathy and the
relative magnitude of the relationship between CU traits and cognitive versus affective empathy

A.

of
ro
-p
re
B.
lP
na
ur
Jo

A. The association between CU traits and lower cognitive empathy was stronger in younger children. B. Cognitive
empathy was more strongly related to CU traits than affective empathy in younger children whereas affective empathy was
more strongly related to CU traits than cognitive empathy in older children.
 Journal Pre-proof

Figure 4. In moderation analyses, informant moderated the relationship between CU traits

and cognitive empathy and the relative magnitude of the relationship between CU traits
and cognitive versus affective empathy.
A.

of
ro
-p
re
lP

B.
na
ur
Jo

A. CU traits were more strongly related to lower cognitive empathy based on parent/teacher reports compared to child self reports. B.
CU traits were more strongly related to lower cognitive empathy than lower affective empathy based on parent/teacher reports
compared to child self reports
 Journal Pre-proof

of
ro
-p
re
lP
na
ur
Jo
 Journal Pre-proof

Highlights

 Callous-unemotional (CU) traits predict risk for severe antisocial behavior

 We need better understanding of the core correlates of CU traits

 Higher CU traits were correlated with lower empathy, prosociality, and guilt

 Effect sizes were in the moderate-to-large range across 59 studies

 Effects mostly did not differ based on sex, age, or severity of antisocial behavior

of
ro
-p
re
lP
na
ur
Jo
 Journal Pre-proof

Conflict of interest statement

No conflicts declared. This research did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors.

of
ro
-p
re
lP
na
ur
Jo
Figure 1
Figure 2
Figure 3
Figure 4