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Comprehensive Psychiatry 69 (2016) 116 – 131
www.elsevier.com/locate/comppsych

Exploring the clinical utility of the DSM-5 conduct disorder specifier of

‘with limited prosocial emotions’ in an adolescent inpatient sample
Salome Vanwoerden a , Tyson Reuter a , Carla Sharp a, b, c,⁎
a
University of Houston, 126 Heyne Building, Houston, TX 77204, USA
b
The Menninger Clinic, 12301 Main Street, Houston, TX 77035, USA
c
Centre for Development Support, University of the Free State, South Africa

Abstract

Background: With the recent addition of a callous-unemotional (CU) specifier to the diagnosis of conduct disorder (CD) in the DSM-5,
studies are needed to evaluate the clinical utility of this specifier and the best ways to identify youth meeting criteria for this specifier in
clinical samples.
Methods: To this end, the current study examined cross-sectional correlates and treatment response across four groups of inpatient
adolescents (N = 382, ages 12–17): those with CD without the specifier, with CD and the CU specifier, CU alone, and a group of psychiatric
controls. We used two different measures to identify adolescents with high levels of CU traits: the Antisocial Process Screening Device
(APSD) [1] and the Inventory of Callous-Unemotional Traits (ICU) [2]. Questionnaires and structured interviews were used to evaluate a
range of outcomes including presence of baseline levels and treatment outcomes of both externalizing and internalizing problems.
Findings: Results indicated that the ICU, but not the APSD differentiated between conduct disordered youth with and without the specifier
on externalizing behaviors in both cross-sectional relations and treatment response.
Conclusions: The results of the current study caution the use of the most frequently used measure to identify the CU specifier, and make
suggestions about alternatives.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction levels of aggression and moderately associated with depressive

The latest version of the DSM-5 includes a new specifier to
the diagnosis of conduct disorder (CD), which is intended to
identify a subgroup of children with CD who have high levels
of callous-unemotional (CU) traits. The specifier was originally
proposed by Frick and Moffitt [3] and consists of four criteria:
lack of remorse or guilt, callous-lack of empathy, unconcerned
about performance, and shallow or deficient affect [4]. Two of
these four criteria are required to be present over at least
12 months in multiple relationships and settings in order to
receive the specifier diagnosis. The justification behind the
development of the specifier is based on a wealth of research that
has evaluated the additive effects of callous-unemotional (CU)
traits in youth with conduct disorder (CD) in regard to a variety of
negative outcomes. For instance, in cross-sectional studies, CU
traits have been shown to be strongly associated with elevated
⁎ Corresponding author. Tel.:+1 713 743 8612; fax: + 1 713 743 8633.
E-mail address: csharp2@central.uh.edu (C. Sharp).
http://dx.doi.org/10.1016/j.comppsych.2016.05.012
0010-440X/© 2016 Elsevier Inc. All rights reserved.
symptoms regardless of gender in antisocial youth [5–8].
Complementing the cross-sectional research of the additive
effects of CU traits in antisocial youth, longitudinal research
has shown CU traits to be highly stable across short time spans
(e.g., ICC = .71 over four years) [9], but moderately stable
across longer time spans (e.g., up to eleven years) [10,11] with
youth high on CU traits showing lower stability estimates [9].
Further, CU traits have been shown to be predictive of diagnoses
of psychopathy in adulthood, with good specificity and negative
predictive power, but with adequate sensitivity and poor positive
predictive power [11]. CU traits are also predictive of other
psychopathology [12]. Longitudinal links have been demon-
strated between CU traits and frequency and severity of offenses
[13], and antisocial behavior [14], regardless of the age of onset
of CD [15]. Studies examining treatment outcomes of antisocial
youth with CU traits have also shown these individuals to be less
responsive to treatment compared to those without CU traits
[16–18]. Specifically, there were moderate to large differences
between antisocial youth with and without CU traits being
 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131
treated with behavioral therapy alone, but negligible to moderate
effect sizes in comparing treatment response of these youth
receiving behavioral therapy with stimulant medications [18].
Additionally, a comprehensive review by Frick and White [19]
reported that CU traits predicted differential characteristics
across social, cognitive, emotional, and personality domains
among antisocial youth. Based on these cross-sectional and
longitudinal studies examining CU traits, it was included as a
specifier to the diagnosis of conduct disorder, defined in the
DSM-5 as “with limited prosocial emotions” [4].
While the above research was imperative in establishing a
rationale for developing the specifier, studies are necessary to
evaluate the utility of the specifier in clinical settings. Further, as
the evidence base in relation to the new specifier grows,
methodological questions arise of how the specifier differen-
tially functions across samples, genders, and instruments. The
development of a clinical assessment for the specifier is
underway (The Clinical Assessment of Prosocial Emotions)
[20]; however current studies largely rely on the Antisocial
Process Screening Device [1] to assess for the presence of the
specifier. To our knowledge, five studies have thus far examined
the clinical utility of the new specifier with the APSD. These
studies used four items from the callous-unemotional subscale to
identify children and adolescents who meet criteria for the CU
specifier [17,21–24]. Kolko and Pardini [17] studied a group of
outpatient children aged 6 to 11 and found that the CU specifier
(as reported by teachers) did not predict pre- or post-treatment
impairment or externalizing symptoms. Their sample included
children with both oppositional defiant disorder and conduct
disorder. Kahn et al. [22] studied two large adolescent samples
from outpatient clinics and the community and found that the
specifier (using combined ratings from teachers and parents in
the community sample and combined youth and parent ratings
in the clinic-referred sample) predicted higher severity on
indices such as aggression and cruelty in their samples, with
medium to high effect sizes in the clinical sample and high effect
sizes in the community sample. McMahon et al. [23] found that
in a community sample of adolescents, diagnosis of conduct
disorder with the specifier (parent report) had the highest
specificity (.99) and positive predictive value (.89) of antisocial
outcomes post-high school compared to a diagnosis of conduct
disorder without the specifier. Pardini et al. [24] found that the
CU specifier (caretaker and teacher report) was predictive of a
variety of negative outcomes over a 6 year period (childhood
through adolescence) in a large community sample of girls.
Finally, Colins and Andershed [21] found that in a sample of
detained adolescent girls, the CU specifier did not predict greater
psychiatric morbidity or internalizing problems compared to
girls with CD only as measured with self-reports.
In all, these studies seem to suggest a pattern of results where
the specifier demonstrates clinical utility in community
samples, but not always in clinical or detained samples. This
raises the question whether the specifier is capturing “general
psychopathology” [25], which predicts a range of poor
outcomes in community samples, but fails to capture a more
discreet and clinically useful construct in clinical samples
117
where overall rates of psychopathology are higher. However,
this conclusion is tempered by the fact that methodological
issues may account for the negative findings for clinical
samples, such as the use of different informants and inclusion of
youth with ODD. Clearly there is a need for more multi-method
studies in clinical samples (especially inpatient samples where
severity of psychiatric problems is greater) to clarify whether
the lack of support for the specifier in the aforementioned
studies of clinical populations are due to specific study
characteristics or represent a real lack of clinical utility of the
specifier [26]. In fact, Cleckley's original formulation of
psychopathy was based on his experiences with male psychiatric
patients and not patients in forensic settings [27].
In addition, given that the APSD is currently the most-often
used assessment tool to identify youth who meet criteria for the
CU specifier, studies are needed to clarify whether the APSD
items which are included almost verbatim in the DSM are
optimal for operationalizing the CU specifier. The APSD items
in question include “Does not feel bad or guilty when he/she
does something wrong” (Lack of remorse or guilt), “Is
unconcerned about the feelings of others” (Callous-lack of
empathy), “Is not concerned about how well he/she does at
school/work (Unconcerned about performance), and “Does not
show feelings or emotions” (Shallow or deficient affect). It is
possible that these four items lack the depth and breadth to
distinguish youth in clinical samples with CU traits from other
psychiatric patients without CU traits. Moreover, there has
been accumulating evidence calling into question the psycho-
metric properties of the CU subscale of the APSD, specifically
with poor internal consistency of these four items [28,29] and it
is possible that negative findings using the APSD to capture the
specifier are due to the use of a non-optimal measure rather than
a problem with the CU specifier itself. Two additional studies
have utilized alternative methods of operationalizing the CU
specifier [21,30] with the Inventory of Callous-Unemotional
Traits (ICU) [2] and the Youth Psychopathic Inventory (YPI)
[31]. When using the ICU and YPI to separately operationalize
the CU specifier among detained adolescent girls, results
demonstrated that the specifier had additive value in predicting
aggressive, rule-breaking, and delinquent behavior above CD,
with medium effect sizes. When comparing these effect sizes
found using these two measures, there were no significant
differences suggesting that group differences did not change
when the YPI was used instead of the ICU [21]. The YPI
additionally did not provide incremental validity in regard to
the CU specifier among detained boys [30]. More studies are
needed to evaluate the specifier using alternative measures that
have more promising psychometric properties. Additionally, in
order to interpret these studies in the context of past findings,
using both the APSD along with newer, more psychometrically
sound measures may shed light on the shortcomings of
the APSD.
Finally, the clinical utility of the CU specifier needs to be
studied in relation to outcomes beyond externalizing behavior
[5]. Specifically, anxiety has been proposed to be a main
differentiating factor between individuals with persistent
118 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131
antisocial behavior [32]. In fact, comorbid anxiety disorder
ranges from 60% to 75% in those with CD compared to
22–30% of the general population [33]. It has further been
suggested that internalizing problems may moderate the
severity of antisocial behavior such that in aggressive children,
internalizing symptoms increases the risk of future aggressive
behavior [34]. In line with this hypothesis, Fanti and colleagues
[35] found that individuals with elevated CU traits and anxiety
reported greater impulsivity, externalizing behavior, and
aggression compared to those with low levels of anxiety,
with large effect sizes. While these studies support the notion
that CD and CU in the presence of internalizing is an indicator
of greater severity and negative outcomes, the relation between
CD and anxiety is complicated when considering the presence
of CU traits as some studies have found CU traits to negatively
correlate with anxiety, although with small magnitude of effects
[6,36]. Findings by Pardini and colleagues [24] supported this
as conduct disordered youth with the CU specifier had lower
anxiety problems compared to those with CD alone suggesting
that anxiety may be a protective mechanism in the development
of CU traits. However, other studies have found that high levels
of anxiety may indeed co-occur with CU traits [35,37]. For
example, in a study by Euler and colleagues [37], cluster
analyses revealed three groups of conduct disordered youth
living in child welfare and justice institutions: one with high
CU and anxiety, one with high CU and average anxiety, and a
third with CD only. Findings showed that the group with CD
and elevated CU and anxiety had the most severe comorbid
psychopathology suggesting that anxiety may represent an
additional criteria to distinguish between CD + CU youth
rather than an a differentiating factor between CD youth with
and without CU traits. Despite mixed evidence of anxiety being
a differentiating factor between CD and CD + CU, only two of
the studies that have examined the clinical utility of the specifier
have included outcome measures specific to internalizing.
Against this background, the first aim of the present study
was to explore the clinical utility of the DSM-5 CU specifier in
an inpatient sample of adolescents. We identified four groups
in accordance to the DSM-5 criteria using the APSD as
executed by previous studies: (1) a CD only group, not
meeting criteria for the CU specifier (CD); (2) a group meeting
criteria for both CD with the CU specifier (CD + CU); (3) a
group with the CU specifier, but not CD (CU); and (4) a group
that did not meet any criteria for CD or the CU specifier
(Control). Including a psychiatric control group was important
in order to distinguish the diagnostic groups of interest from
adolescents with severe psychiatric problems in order to
determine whether the specifier is capturing pathology or a
construct unique to CD and CU. Additional inclusion of a group
of CU only adolescents is important given that few studies have
included a comparison group of youth with significant CU traits
without CD and as suggested by the findings of Kahn et al. [22],
this group of youth presents another clinically relevant group to
be studied in regard to antisocial correlates.
We expected to see cross-sectional differences across groups
such that the group meeting criteria for CD + CU would have
the highest elevations across all broad measures of psychiatric
severity, internalizing, and externalizing, as well as on specific
measures of aggression, CD symptoms, ODD symptoms,
anxiety and depression as reported by both youth and parents
on questionnaires and interview based measures. We expected
that when looking at a specific measure of anxiety, with the CD
only group would demonstrate greater severity of anxiety
symptoms compared to the CD + CU group. Previous findings
suggest that youth with CD + CU may demonstrate an overall
greater level of emotional problems [38], including depressive
or dysthymic symptoms [39] and overall negative affect [40].
This may be best captured with a broadband measure of
internalizing problems, given that broadly, the internalizing
dimension refers to psychopathology characterized by negative
affect expressed inward [41]. However, results are expected to
be different when considering pure anxiety symptoms. In fact,
previous findings suggest that anxiety, which is differentiated
from depression by greater physiological arousal [42], may act
as a protective factor from CU among CD youth. Therefore, in
order to capture the complex relations between CU, CD, and
internalizing problems, we included narrowband measures of
anxiety and depression along with our broadband measure of
internalizing symptoms in order to elucidate group differences
between these related, but distinct forms of internalizing
problems. Lastly, we had no a priori hypotheses regarding the
CU only group as this group has only been examined in one
previous study. Using the APSD for this first aim is important in
order to contextualize our findings with the majority of previous
literature that has used the APSD to operationalize the specifier.
Second, given issues discussed earlier regarding potential
limitations of the APSD items to effectively operationalize the
CU specifier, we replicated our aims while using the ICU,
which was developed specifically for identifying children and
adolescents with CU traits and represents one of the most
comprehensive measures of CU traits [3]. There have only
been two studies thus far utilizing the ICU to test the utility of
the new DSM-5 specifier among community and incarcerated
youth [21,43] with limited findings. Given that there does not
exist any measure specifically designed to assess for the
DSM-5 criteria, research utilizing existing measures of CU
traits is necessary to evaluate the specifier in a variety of
samples. Therefore, we re-categorized the same groups as
previously mentioned using the ICU and tested the clinical
utility within these new groups. Drawing on a recent study [43]
that used Item Response Theory to evaluate the DSM-5
specifier criteria in two samples, we used an 8-item set, which
is described in more detail in the methods section of the current
study. This study evaluated criteria in both a community and
incarcerated sample cross-nationally. We utilized the item set
shown to have the best discriminative properties in the
incarcerated sample versus the set found from the community
sample. This decision was based on the higher level of
psychiatric severity likely present in the incarcerated sample
relative to the community sample, which would best align with
our inpatient sample of adolescents who are (as described in
the methods section) treatment refractory and highly severe.
 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131
Given that this is the first study to explore the use of the ICU
for this purpose in a clinical sample of youth, this aim of
the study is highly exploratory and is viewed as a first attempt
in using alternative approaches to identifying inpatient
adolescents who meet criteria for the CU specifier.
Our third aim was to explore whether meeting criteria for the
CU specifier would affect response to treatment using both of
our methods of operationalizing the CU specifier (APSD and
ICU), specifically in regard to measures of broadband
psychiatric severity, internalizing, and externalizing as well as
specific measures of aggression, anxiety, and depression. Only
one other study has examined differential treatment response
based on the presence of the CU specifier [17]. Although there
were no differences between CD youth with and without the CU
specifier, this study had several methodological issues including
not accounting for pre-treatment levels of outcome measures,
only one informant source for diagnostic status, and the
inclusion of youth with ODD in addition to CD. We expected
to see patterns demonstrating slower treatment response across
all outcome measures in the CD + CU group relative to the CD
group, given previous literature suggesting that, although with
small or moderate effects, youth with CU may be less responsive
to treatment [16–18]. However, given the exploratory nature of
this question, we did not have any a priori hypotheses for the CU
only group.
2. Method
2.1. Participants
Adolescents were recruited from a 16-bed inpatient
psychiatric unit. Inclusion criteria were sufficient proficiency
in English to consent to research and complete the necessary
assessments, and exclusion criteria were a diagnosis of
schizophrenia or another psychotic disorder, an autism
spectrum diagnosis, or an IQ of less than 70. Of N = 481
adolescents who were approached for consent, 35 declined
participation, 2 revoked consent, and 51 were excluded on the
basis of the aforementioned criteria. Additionally, 5 participants
were excluded due to missing data. Analyses comparing
patients who participated in the study and those who did not due
to the above reasons showed no differences in age (t = − 1.50,
df = 479, p = .133) or gender (χ 2(1, n = 481) = .030, p =
.862). The remaining adolescents and parents provided written
informed consent. The final sample consisted of N = 382
adolescents (ages 12–17; Mage 15.37; SD = 1.43), including
239 (62.6%) females and 143 (37.4%) males, and had the
following ethnic breakdown: 75.1% White (n = 287), 5.8%
Hispanic (n = 22), 3.1% Asian (n = 12), 2.1% Black (n = 8),
and 13.9% Mixed or other (n = 53). Based on DSM-IV criteria,
50.3% were diagnosed with a depressive disorder, 6.8% were
diagnosed with bipolar disorder, 7.9% were diagnosed with an
eating disorder, 41.6% were diagnosed with an externalizing
disorder, and 53.4% were diagnosed with an anxiety disorder.
Upon admission, reasons cited that contributed to the present
hospitalization included suicidal or self-injurious behaviors or
119
plans (33.5%); escalating oppositional, impulsive, or risky
behavior (30.1%); decline in functioning (22%); failed
outpatient, inpatient, or medication treatment (19.9%); school
problems or truancy (9.2%); aggression or rage (7.6%);
substance use (7.1%); transfer from an acute level of care
(5.8%); traumatic event (4.5%); running away (2.9%);
diagnostic clarity (2.9%); and legal problems (2.9%).
2.2. Measures
The Antisocial Process Screening Device (APSD) [1] is a
20-item self-report measure designed to assess traits associated
with the construct of psychopathy. Each item on the APSD is
scored either 0 = “not at all true”, 1 = “sometimes true”, or
2 = “definitely true”. For our purposes, we utilized the four
items that map onto the DSM-5 specifier criteria that have been
used in previous studies. Two or more items had to be rated a 2
to deem criteria present. The APSD was completed by both
parents and youth at admission whose ratings were combined
for a final specifier group membership such that if specifier
criteria were met by either parent or youth report, specifier was
deemed present. The four items used for the purposes of this
study had an internal consistency of α = .52 for parent report
and α = .45 for youth report.
The Inventory for Callous Unemotional Traits (ICU) [2] is a
24-item self-report measure used to rate callous-unemotional
(CU) traits in youth. The ICU was completed by youth at
admission for the present study. The ICU was derived from the
6-item CU scale of the Antisocial Process Screening Device
(APSD) [44] to overcome moderate internal consistencies and
response-bias limitations. Of the six CU items used in the APSD,
four items loaded significantly onto the callous-unemotional
scale in both clinic and community samples [45]. These items
were used as the basis for designing the ICU and the measure
was expanded to total six variations of each original item
(including the original item, verbatim). The resulting 24 items
were placed on a four-point Likert scale (0 = “not at all true”,
1 = “somewhat true”, 2 = “very true”, and 3 = “definitely
true”). Kimonis and colleagues [43] used Item Response
Theory analysis to create a revised 8-item version of the ICU
that best discriminated detained adolescents. They categorized
adolescents who endorsed (reporting a score of 2 or 3) at least
two items in this set as having a significant level of CU traits.
Therefore, we utilized this revised item set to determine
presence of the specifier for our second aim. We used a
split-coding scale, such that items were deemed present if rated
at a 2 or above in line with the method used by Kimonis et al.
Next, specifier was deemed present if at least two items were
endorsed at or above 2. The revised 8-item scale used to
designate those meeting the CU specifier had good internal
consistency (α = .79).
The Computerized Diagnostic Interview Schedule for
Children (C-DISC) [46] is a structured computer-assisted
diagnostic interview used to assess Axis I psychiatric disorders
in children and adolescents between the ages of 9 and 17. The
interviews were administered to caregivers and adolescents
120 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131
(separately) in a private assessment room by doctoral
psychology students or trained clinical research assistants.
The interviewer is required to read a series of computerized
prompts aloud and then the interviewer inputs a response
based on each answer the interviewee provides. For the
purpose of this study, only positive diagnoses that met DSM
criteria on the clinical reports of the C-DISC for the conduct
disorder module were coded as “1,” whereas both intermediate
and negative diagnoses for conduct disorder were coded as “0”
for data analyses. Similar to the APSD, parent and youth
ratings were combined for final group membership.
The Youth Self-Report and Child Behavior Checklist
(YSR and CBCL) [47] are measures of psychopathology
completed by adolescents and their parents, respectively.
Each measure contains 112 problem items, scored on a
3-point scale (0 = “not true”, 1 = “somewhat or sometimes
true”, or 2 = “very or often true”). The measure yields
empirically derived (the Syndrome Scales) and theoretically
based (the DSM-Oriented Scales) scales. The Total Problems
Scale represents level of general psychiatric functioning and
therefore provides and important index of overall severity.
The Internalizing and Externalizing Scales were also used as
outcome measures. The YSR was completed at both
admission and discharge, while the CBCL was only used
to measure group differences at admission.
Peer Conflict Scale-Youth (PCS-Y) [48] is a measure of
aggression for youth. The self-report measure contains 40 items
and respondents are asked to rate how true each statement is
for them on a 4-point Likert scale (0 = “not at all true”, 1 =
“somewhat true”, 2 = “very true”, or 3 = “definitely true”).
The PCS consists of four scales: Reactive Overt (e.g., “When
someone hurts me, I end up getting into a fight”), Reactive
Relational (e.g., “If others make me mad, I tell their secrets”),
Proactive Overt (e.g., “I start fights to get what I want”), and
Proactive Relational (e.g., “I gossip about others to become
popular”). Scales have demonstrated adequate concurrent
validity with emotional and cognitive correlates [7] as well as
with laboratory measures of aggression [49]. Internal consis-
tency in this sample ranged from .86–.89 for the four scales.
The Multidimensional Anxiety Scale for Children (MASC)
[50] is a measure of anxiety symptoms completed by
adolescents. The self-report measure contains 39 items and
respondents are asked to rate how true each statement is for
them on a 4-point Likert scale (0 = “never true”, 1 = “rarely
true”, 2 = “sometimes true”, or 3 = “often true”). The MASC
Total Score was included as an outcome measure. Internal
consistency in this sample was .93.
The Beck Depression Inventory (BDI-II) [51] is a measure
of depression severity completed by adolescents. The
self-report measure contains 21 items, each scored on a
4-point intensity scale (range = 0–3), where each item is
rated with respect to the “past two weeks, including today.”
Total scores are calculated by summing the highest score for
each item (range = 0–63). While reliability and validity have
been established in adolescent inpatient samples as young as
13 years of age [52], use of the BDI-II among 12 year olds is
less common; however, The BDI-II has demonstrated good
psychometric properties with outpatients as young as 12
[53]. Internal consistency in this sample was .93.
2.3. Procedures
This study was approved by the university's institutional
review board and the Baylor College of Medicine committee
and was performed in accordance with the ethical standards
outlined by these institutions for conducting research with
human subjects. First, parents were approached for informed
consent. Once parental consent was received, adolescents were
approached to give assent. All assessments were conducted
privately on the unit by doctoral level psychology students and
trained clinical research assistants under the supervision of the
senior author. Assessments were conducted within one week of
admission and then again one week or less prior to discharge.
Length of stay ranged from 5 to 85 days (M = 34.31, SD =
13.60). During this time, adolescents participated in a
milieu-based, inpatient treatment emphasizing improvement
of social cognitive capacity, emotion regulation, maladaptive
behaviors and family relations. This treatment integrates
cognitive-behavioral and family systems approaches, but the
primary theoretical framework is interpersonal-psychodynamic
[54]. Adolescents participate in intensive psychopharmacologic
and psychotherapeutic interventions (individual and family
therapy twice per week) in addition to structured therapeutic
activities (e.g., equine therapy) daily through the week.
2.4. Data analytic strategy
For the first aim of exploring the clinical utility of the
proposed DSM-5 specifier, participants were divided into four
mutually exclusive groups based on the presence of a diagnosis
of CD and the presence of the CU specifier as described in the
DSM-5 using the Antisocial Process Screening Device (APSD):
a CD only group (CD), CD with specifier (CD + CU), CU only
(CU), and a psychiatric control group that did not meet criteria
for CD or the specifier (Control). Chi-square goodness of fit tests
and analyses of covariance (ANCOVAs) were then run to
compare each of these groups on a variety of psychiatric
problems while controlling for the effects of gender. Results of
these analyses determined whether psychiatric problems
differed significantly across the four diagnostic groups.
Post-hoc tests were run to determine which groups significantly
differed across dependent variables. These were adjusted
for multiple comparisons (6 pairwise comparisons) using
Bonferroni due to unequal sample sizes between groups
resulting in a critical p value of .008 (.05/6).
For the second aim, we categorized our sample as in Aim 1;
however, presence of the CU specifier was determined by level
of CU traits endorsed on the Inventory of Callous-Unemotional
Traits (ICU). Following methods utilized by Kimonis et al.
[55], presence of the specifier was determined using 8 items
from the ICU with a split-coding method such that an item was
considered endorsed if an individual rated it a 2 or 3. Next, a
symptom category was considered present if any of the items
 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131 121

comprising that category was present. Analyses from Aim 1
and Aim 2 were repeated using the new classification method.
For the final aim of exploring treatment gains based on
diagnostic group membership, repeated measures ANOVAs
were conducted with psychiatric problems at admission and
discharge as the within subjects variable and diagnostic group
membership, based on the DSM-5 specifier as the between
subjects variable. This aim was conducted using both the
APSD and ICU. Results of these analyses determined whether
treatment gains were significantly different across the four
diagnostic groups. Attrition analyses were conducted through
the use of independent sample t-tests and chi-square analyses
comparing patients for whom discharge data were available
and those for whom it was not on outcome variables, group
status, gender, and age. Data were missing for discharge
assessments mainly due to sudden, unexpected decisions to
leave the facility initiated by the patient, their parents, or
clinical staff. Missing data rates were variable across measures
(YSR: 21.7%; PCS: 23.6%; MASC: 13.1%; BDI-II: 14.7%).
information as well as rates of comorbid diagnoses. As shown
in Table 1, 88 (23%) of youth were diagnosed with CD only,
25 (6.5%) with CD and the DSM-5 specifier, 37 (9.7%) with the
DSM-5 specifier only, and 232 (60.7%) with neither a CD
diagnosis nor DSM-5 specifier. The groups differed signifi-
cantly by gender, χ 2(3, N = 382) =10.81, p = .01 with the CD
only group having a greater than expected rate of males
(adjusted residual = 3) and psychiatric controls having a lower
than expected rate of males (adjusted residual = − 3). Age was
not shown to be significantly different between groups
(F(3381) = 1.70, p = .167). Given that previous findings
have suggested a higher portion of males with CU traits
[56], analyses were conducted while controlling for gender and
again without gender as a covariate. Because results were not
changed substantially, tables and text reflect results from
analyses that included gender as a covariate; findings that
differed when gender was not included as a covariate are
described in footnotes of tables. Full tables with these results are
available from the authors upon request.

3.2. Group comparisons of psychiatric problems while

3. Results
3.1. Frequencies of the DSM-5 callous-unemotional specifier
when utilizing the APSD
Table 1 summarizes descriptive statistics for each of the four
diagnostic groups, including frequency and basic demographic
controlling for gender when utilizing the APSD
First, chi-square analyses were run to compare groups on
rates of comorbid diagnoses given to each group based on a
diagnostic interview completed with youth (C-DISC), which
are described in Table 1. No differences between groups were
found in the rate of a comorbid depressive disorder χ 2(3, N =

Table 1
Descriptive Statistics of Different Diagnostic Groups.
CD only CD + CU CU only Control Full sample χ 2/F
Descriptive statistics when utilizing APSD
n 88 (23%) 25 (6.5%) 37 (9.7%) 232 (60.7%) 382
Mage (SD) 15.25 (1.38) 14.88 (1.69) 15.62 (1.30) 15.43 (1.43) 15.37 (1.43) 1.70
% Male 51% a 40% 41% 32% b 37% 10.81⁎
Depressive disorder 45.3% 64% 39.4% 52.3% 50.3% 4.63
Bipolar disorder 4.7% 12% 9.1% 6.8% 6.8% 1.96
Eating disorder 8.1% 8% 0% 9% 7.9% 3.19
Externalizing disorder 71.3% a 84% a 21.2% b 28.3% b 41.6% 72.03⁎⁎⁎
Anxiety disorder 46.5% 32% b 50% 58.9% a 53.4% 9.15⁎

Descriptive statistics when utilizing ICU

n 19 (4.9%) 92 (24.1%) 162 (43.8%) 102 (27.2%) 375
Mage (SD) 15.11 (1.63) 15.16 (1.45) 15.50 (1.35) 15.45 (1.46) 15.39 (1.42) 1.11
% Male 47% 49% a 36% 27% b 37% 11.42⁎
Depressive disorder 52.6% 49.5% 53.2% 46.4% 50.4% 1.19
Bipolar disorder 10.5% 5.5% 8.4% 5.2% 6.9% 1.69
Eating disorder 5.3% 8.8% 5.8% 11.3% 8% 2.75
Externalizing disorder 52.6% 78.3% a 32.3% b 19.6% b 41.6% 76.74⁎⁎⁎
Anxiety disorder 63.2% 39.6% b 56.3% 60.2% 53.6% 10.10⁎
Note: Presence of a depressive disorder included percentage of youth in each group with a positive DSM-IV diagnosis for major depressive disorder or
dysthymia; bipolar disorders included hypomania and mania; eating disorders included anorexia and bulimia nervosa; externalizing disorders included attention
deficit hyperactive disorder, oppositional defiant disorder, and conduct disorder; anxiety disorders included post-traumatic stress disorder, generalized anxiety
disorder, separation anxiety disorder, specific phobia, social phobia, obsessive–compulsive disorder, panic disorder, and agoraphobia.
⁎⁎⁎ p b .001.
⁎ p b .05.
a
Greater than expected rate.
b
Less than expected rate.
 122
Table 2
Correlational Matrix of Main Study Variables.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131

1. ICU .65⁎⁎ .40⁎⁎ .47⁎⁎ .24⁎⁎ .04 .11⁎ − .00 .49⁎⁎ .39⁎⁎ .39⁎⁎ .33⁎⁎ .30⁎⁎ .31⁎⁎ .11⁎ .09 − .06 .22⁎⁎
2. APSD .53⁎⁎ .69⁎⁎ .23⁎⁎ .20⁎⁎ .31⁎⁎ .01 .47⁎⁎ .55⁎⁎ .51⁎⁎ .56⁎⁎ .46⁎⁎ .47⁎⁎ .26⁎⁎ .28⁎⁎ .06 .21⁎⁎
3. YSR Total .71⁎⁎ .85⁎⁎ .28⁎⁎ .15⁎⁎ .31⁎⁎ .37⁎⁎ .38⁎⁎ .37⁎⁎ .43⁎⁎ .23⁎⁎ .36⁎⁎ − .02 .12⁎ .54⁎⁎ .61⁎⁎
4. YSR Ext .71⁎⁎ .31⁎⁎ .34⁎⁎ .51⁎⁎ .07 .46⁎⁎ .40⁎⁎ .50⁎⁎ .45⁎⁎ .56⁎⁎ .58⁎⁎ .40⁎⁎ .46⁎⁎ .05 .15⁎
5. YSR Int .88⁎⁎ .44⁎⁎ .10 − .17⁎⁎ .39⁎⁎ .19⁎⁎ .23⁎⁎ .15⁎⁎ .24⁎⁎ − .04 .09 − .32⁎⁎ − .17⁎⁎ .67⁎⁎ .73⁎⁎
6. CBCL Total .77⁎⁎ .67⁎⁎ .14⁎⁎ .11⁎ .20⁎⁎ .19⁎⁎ .20⁎⁎ .30⁎⁎ .39⁎⁎ .52⁎⁎ .13⁎ .05
7. CBCL Ext .19⁎⁎ .15⁎⁎ .14⁎⁎ .25⁎⁎ .20⁎⁎ .40⁎⁎ .42⁎⁎ .60⁎⁎ .73⁎⁎ − .17⁎⁎ − .16⁎⁎
8. CBCL Int .05 .05 .03 .07 − .07 .02 − .02 .08 .35⁎⁎ .25⁎⁎
9. Proact-Overt .41⁎⁎ .50⁎⁎ .27⁎⁎ .75⁎⁎ .75⁎⁎ .65⁎⁎ .35⁎⁎ .40⁎⁎ .14⁎⁎ .16⁎⁎ .05 .11
10. Proact-Relat .38⁎⁎ .46⁎⁎ .26⁎⁎ .80⁎⁎ .51⁎⁎ .83⁎⁎ .19⁎⁎ .34⁎⁎ .03 .15⁎⁎ .15⁎ .21⁎⁎
11. React-Overt .40⁎⁎ .52⁎⁎ .24⁎⁎ .77⁎⁎ .58⁎⁎ .56⁎⁎ .37⁎⁎ .43⁎⁎ .24⁎⁎ .25⁎⁎ .08 .10
12. React-Relat .39⁎⁎ .45⁎⁎ .27⁎⁎ .69⁎⁎ .81⁎⁎ .64⁎⁎ .20⁎⁎ .38⁎⁎ .10⁎ .24⁎⁎ .15⁎ .20⁎⁎
13. DISCY CD .54⁎⁎ .60⁎⁎ .32⁎⁎ − .13⁎ − .07
14. DISCY ODD .34⁎⁎ .50⁎⁎ .02 .05
15. DISCP CD .54⁎⁎ − .27⁎⁎ − .31⁎⁎
16. DISCP ODD − .13⁎ − .15⁎
17. MASC .63⁎⁎ .23⁎⁎ .69⁎⁎ .09 .12 .12 .13⁎ .57⁎⁎
18. BDI-II .72⁎⁎ .36⁎⁎ .74⁎⁎ .30⁎⁎ .25⁎⁎ .23⁎⁎ .22⁎⁎ .53⁎⁎
Correlation coefficients above the diagonal represent correlations of outcome measures at admission; coefficients below the diagonal represent correlations of outcome measures at discharge. DISC, CBCL, APSD,
and ICU were not conducted at discharge and therefore are not included in correlations at discharge. ICU = Inventory of Callous-Unemotional Traits; APSD: Antisocial Process Screening Device — youth report;
YSR = Youth Self-Report: Total Problems, Externalizing, Internalizing; Aggression measured with the Peer Conflict Scale: Proactive-Overt Aggression Subscale, Proactive-Relational Aggression Subscale,
Reactive-Overt Aggression Subscale, and Reactive-Relational Aggression Subscale; DISC = Diagnostic Interview Schedule for Children (youth and parent report): CD = Conduct Disorder, number of symptoms,
ODD = Oppositional Defiant Disorder, number of symptoms; MASC = Multidimensional Anxiety Scale for Children; BDI-II = Beck Depression Inventory-II.
⁎⁎ p b .01.
⁎ p b .05.
 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131 123

366) = 4.63, p = .20; bipolar disorder χ (3, N = 366) = 1.96,

2
p = .58; or eating disorder χ 2(3, N = 367) = 3.19, p = .36.
However, there were cell sizes of n b 5 in the analyses for bipolar
and eating disorders; therefore, these results are uninterpretable.
Groups were significantly different in the rate of a comorbid
externalizing disorder χ 2(3, N = 368) = 72.03, p ≤ .01 and an
anxiety disorder χ 2(3, N = 368) = 9.16, p =.03; the CD + CU
and CD only groups had a greater than expected rate of
externalizing disorders (adjusted residual = 4.5, 6.4, respectively)
whereas the CU only and control groups had a lower than
expected rate (adjusted residual = −2.5, −6.5, respectively). The
psychiatric control group had a higher than expected rate of
anxiety disorders (adjusted residual = 2.6) and the CD + CU
group had a lower than expected rate (adjusted residual = −2.2).
A series of one-way analyses of covariance (ANCOVA)
were conducted to assess differences in various psychiatric
problems across the four diagnostic groups while controlling for
gender with results demonstrated in Table 3. Outcome variables
(e.g., YSR internalizing score) were entered as the dependent
variables, with diagnostic group membership entered as the
fixed factor variable and gender as a covariate. Table 2 lists
correlations between all main study variables. As shown in
Table 3, significant group differences were found for all main
study variables except for YSR Total Score and Internalizing;
CBCL Internalizing; and BDI-II. Effect sizes (ηp2) were small
for MASC and proactive-relational aggression (.033, .044);
medium for reactive-relational aggression, reactive-overt
aggression, proactive-overt aggression, and CBCL Total
Problems (.067–.113); and large for parent and youth reported
ODD and CD symptoms on the DISC and CBCL and YSR
Externalizing (.145–.282). Post-hoc tests (Bonferroni) were
then conducted with all significant ANCOVAs. Results showed
that the CD + CU group did not differ from the CD only group
on any of the outcomes; however, these groups had consistently
worse outcomes across self- and parent-reported measures of
internalizing and externalizing when compared to the CU only
group and the psychiatric controls. Interestingly, on the
aggression measure (PCS-Y), the CD + CU group was higher
than the control group only on the scale of reactive-relational
aggression although this was insignificant.

Table 3
Group Comparisons Operationalized with APSD of Psychiatric Symptoms Controlling for the Effects of Gender.
CD only CD + CU CU only Control Test statistic ηp2
(n = 86) (n = 25) (n = 36) (n = 229)
YSR Total 66.15 (9.24) 65.80 (14.15) 63.50 (10.60) 64.27 (10.22) F(3371) = 2.12 .017
YSR Ext 67.59 (8.39) b 66.40 (12.43) b 59.50 (10.79) a 58.73 (9.41) a F(3371) = 20.93⁎⁎⁎ .145
YSR Int 61.73 (11.95) 62.24 (15.18) 63.81 (12.53) 64.88 (12.37) F(3371) = 1.19 .010
(n = 85) (n = 24) (n = 36) (n = 222)
CBCL Total 71.55 (5.94) b 74.25 (4.74) b 66.92 (7.51) a 67.99 (6.47) a F(3362) = 15.39⁎⁎⁎ .113
CBCL Ext 70.59 (6.97) b 72.71 (4.85) b 63.03 (9.11) a 62.17 (8.96) a F(3362) = 31.30⁎⁎⁎ .206
CBCL Int 70.92 (6.94) 72.08 (8.76) 68.72 (7.66) 71.04 (7.20) F(3362) = 1.27 .010
(n = 86) (n = 25) (n = 36) (n = 228)
Proact-Overt 3.52 (4.30) b 3.36 (5.31) b 2.19 (4.12) 1.23 (2.50) a F(3370) = 10.96⁎⁎⁎ .082
Proact-Relat 2.95 (3.99) 3.44 (6.01) b 3.28 (5.90) 1.62 (2.92) a F(3370) = 5.68⁎⁎ .044
React-Overt 7.19 (6.31) b 6.44 (6.92) b 3.03 (4.91) a 3.05 (4.35) a F(3370) = 15.53⁎⁎⁎ .112
React-Relat 5.15 (4.65) b 5.00 (6.06) 4.94 (6.71) b 3.00 (3.68) a F(3370) = 8.85⁎⁎⁎ .067
(n = 87) (n = 25) (n = 33) (n = 222)
DISCY CD 8.78 (4.62) b 7.84 (5.30) b 3.45 (3.16) a 3.24 (3.29) a F(3362) = 46.92⁎⁎⁎ .280
DISCY ODD 8.14 (2.57) b 7.20 (3.08) b 4.73 (2.35) a 5.13 (2.73) a F(3362) = 32.31⁎⁎⁎ .211
(n = 88) (n = 23) (n = 36) (n = 222)
DISCP CD 7.10 (3.87) b 6.91 (3.30) b 2.47 (2.30) a 2.56 (3.02) a F(3364) = 47.67⁎⁎⁎ .282
DISCP ODD 9.25 (2.52) b 9.96 (2.16) b 6.50 (3.15) a 6.21 (3.34) a F(3365) = 28.99⁎⁎⁎ .192
(n = 68) (n = 19) (n = 19) (n = 189)
MASC 53.74 (14.02) 50.11 (15.83) 48.95 (15.60) 57.31 (14.11) F(3290) = 3.31⁎ .033
(n = 68) (n = 19) (n = 21) (n = 193)
BDI-II 21.75 (13.59) 26.63 (14.55) 23.48 (11.31) 25.74 (14.21) F(3296) = .460 .005
YSR = Youth Self-Report: Total Problems, Externalizing, Internalizing; CBCL = Child Behavior Checklist: Total Problems, Externalizing, Internalizing;
Aggression measured with the Peer Conflict Scale: Proactive-Overt Aggression Subscale, Proactive-Relational Aggression Subscale, Reactive-Overt Aggression
Subscale, and Reactive-Relational Aggression Subscale; DISC = Diagnostic Interview Schedule for Children (youth and parent report): CD = Conduct
Disorder, number of symptoms, ODD = Oppositional Defiant Disorder, number of symptoms; MASC = Multidimensional Anxiety Scale for Children;
BDI-II = Beck Depression Inventory-II. In parallel analyses conducted without controlling for gender, CD + CU group did not have greater symptoms on
Proactive-Relational aggression compared to controls; however, the CD group was significantly higher than controls. In pair-wise comparisons of
Reactive-Overt aggression, only the CD + CU and control groups were significantly different from each other. In regard to Reactive-Relational aggression, only
the CD and control groups were significantly different from each other.
⁎⁎⁎ p b .001.
⁎⁎ p b .01.
⁎ p b .05.
a
p b .05 Bonferroni from.
b
Bonferroni corrections were based on 6 total pairwise comparisons resulting in a critical p value of .008 (.05/6).
124 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131
3.3. Frequencies of DSM-5 callous-unemotional specifier
utilizing the ICU
Next, we created the same diagnostic groups utilizing the
ICU following the procedure described previously and
utilized by Kimonis et al. [43], which was found to best
discriminate detained youth using DSM-5 diagnostic criteria
for the ‘with limited prosocial emotions’ specifier. Table 1
summarizes descriptive statistics for each of the four
diagnostic groups, including prevalence and basic demo-
graphic information. Cohen's kappa was calculated to
determine how similar classification was across methods.
Results demonstrated that κ = .251 indicating fair agreement
across categories [57], which was largely driven by a higher
portion of youth being identified as having the CU specifier.
As shown in Table 1, 19 (4.9%) of youth were diagnosed
with CD only, 92 (24.1%) with CD and the CU specifier, 162
(43.8%) with the CU specifier without a diagnosis of CD,
and 102 (27.2%) without a diagnosis of CD or the specifier.
The groups differed significantly by gender, χ 2(3, n =
375) = 11.42, p = .01 with the CD + CU group having a
greater than expected rate of males (adjusted residual = 2.7)
and the psychiatric control group having a less than expected
rate of males (adjusted residual = − 2.6). Age was not shown
to be significantly different between groups (F(3374) =
1.11, p = .347). Therefore only gender was controlled for in
subsequent analyses of variance. As in previous analyses,
ANCOVAs were repeated without gender included as a
covariate and although not substantial, results from these
analyses that differed from results with gender as a covariate
are included as footnotes.
3.4. Group comparisons of psychiatric problems while
controlling for gender utilizing the ICU
Chi-square analyses were run to compare groups on rates
of comorbid diagnoses given to each group based on a
diagnostic interview completed with youth (C-DISC) and are
displayed in Table 1. No differences between groups were
found in the rate of a comorbid depressive disorder χ 2(3,
N = 361) = 1.19, p = .76; bipolar disorder χ 2 (3, N =
361) = 1.69, p = .64; or eating disorder χ 2(3, N = 362) =
2.75, p = .43. However, there were cell sizes of n b 5 in the
analyses for bipolar and eating disorders; therefore, these
results are uninterpretable. Groups were significantly
different in the rate of a comorbid externalizing disorder
χ 2(3, N = 363) = 76.76, p ≤ .001 and an anxiety disorder
χ 2(3, N = 363) = 10.10, p = .02; the CD + CU group had
greater than expected rate of externalizing disorders (adjusted
residual = 8.3) whereas the CU only and control groups had a
lower than expected rate (adjusted residual = − 3.1, − 5.1,
respectively). The CD + CU group had a lower than expected
rate of comorbid anxiety disorders (adjusted residual = − 3.1).
A series of one-way analyses of covariance (ANCOVA)
were conducted to assess differences in various psychiatric
problems across the four groups while controlling for gender.
The same outcome variables as used in the first set of analyses
were entered as dependent variables, with diagnostic group
membership entered as the fixed factor variable and gender as a
covariate. As shown in Table 4, significant group differences
were found for all main study variables except for CBCL
Internalizing and MASC. Effect sizes (ηp2) were small for BDI,
YSR Internalizing and Total Problems, and proactive-relational
aggression (.021–.059); medium for reactive-relational aggres-
sion, proactive-overt aggression, and CBCL Total Problems
(.064–.117); and large for reactive-overt aggression, parent and
youth reported ODD and CD symptoms on the DISC and
CBCL and YSR Externalizing (.142–.282). Post-hoc tests
(Bonferroni) were then conducted with all significant ANCO-
VAs, and results showed that the control group and the CU only
group were the same on all variables except for YSR Total
Problems and Externalizing, proactive-overt aggression, youth
reported DISC ODD symptoms, and BDI-II, for which the
control group had the lowest levels of each. The CD only
group had significantly higher levels than the CU only and
psychiatric control group on CBCL Total Problems and
Externalizing as well as parent and youth reported DISC
symptoms. On CBCL Externalizing and proactive-overt
aggression, the CD only group scored similarly to the CU
only group, which was higher than the psychiatric control group.
On YSR Externalizing, proactive-overt aggression, and
youth-reported DISC CD symptoms, the CD + CU group
scored higher than the CD only group; however, on CBCL Total
Problems and Externalizing, proactive-relational aggression,
reactive-relational aggression, youth-reported DISC ODD
symptoms, parent-reported DISC symptoms, and BDI-II, the
CD + CU and CD only groups scored at similar levels.
3.5. Attrition analyses
We conducted independent sample t-tests for continuous
variables (age, psychopathology outcomes, and aggression at
baseline) and chi-square tests for gender and group status
between those for whom discharge data were not obtained to
determine whether any systematic differences existed that
could bias findings. Because missing data were variable based
on which outcome variable being measured, these analyses
were conducted based on completion of the measure with the
highest attrition (PCS: 23.6%). Results showed that there were
no significant differences on any of the categorical variables
(χs = .169–4.358, ps = .681–.225) or continuous variables
(ts = .047–1.66, ps = .963–.098) except for YSR Internalizing
(t = − 2.48, df = 367, p = .014). Specifically, those who
completed discharge data had higher levels of internalizing
(M = 64.81, SD = 11.97) compared to those who did not
complete discharge data (M = 61, SD = 14.14).
3.6. Group comparisons of changes in psychiatric problems
between admission and discharge utilizing the APSD
A series of repeated measures ANOVAs were conducted to
assess reductions in psychiatric problems across admission
and discharge for the four diagnostic groups and are displayed
in Table 5. First, length of stay was compared across groups to
 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131 125

Table 4
Group Comparisons Operationalized with ICU of Psychiatric Symptoms Controlling for the Effects of Gender.
CD only CD + CU CU only Control Test statistic ηp2
(n = 19) (n = 90) (n = 160) (n = 100)
YSR Total 61.37 (14.34) 66.92 (9.25) b 65.11 (9.49) b 60.92 (10.48) a F(3364) = 7.62⁎⁎⁎ .059
YSR Ext 61.47 (11.05) b 68.27 (8.47) c 61.01 (8.75) b 55.18 (9.90) a F(3364) = 32.75⁎⁎⁎ .213
YSR Int 58.21 (17.31) 62.62 (11.58) 65.69 (11.94) 63.35 (13.10) F(3364) = 2.62⁎ .021
(n = 18) (n = 89) (n = 155) (n = 98)
CBCL Total 72.83 (5.15) b 71.99 (5.94) b 67.60 (6.83) a 68.42 (5.93) a F(3355) = 13.72⁎⁎⁎ .104
CBCL Ext 71.61 (5.87) b 70.94 (6.56) b 62.50 (8.70) a 61.96 (9.33) a F(3355) = 30.13⁎⁎⁎ .203
CBCL Int 72.50 (6.40) 70.87 (7.59) 70.53 (7.28) 71.18 (7.23) F(3355) = .682 .004
(n = 19) (n = 92) (n = 162) (n = 102)
Proact-Overt 1.32 (1.64) b 3.93 (4.80) c 1.81 (3.26) b .62 (1.55) a F(3370) = 16.41⁎⁎⁎ .117
Proact-Relat 2.16 (2.79) 3.25 (4.76) b 2.25 (3.62) 1.21 (3.24) a F(3370) = 5.71⁎⁎ .044
React-Overt 3.58 (3.55) a 7.73 (6.67) b 3.45 (4.73) a 2.40 (3.83) a F(3370) = 20.44⁎⁎⁎ .142
React-Relat 4.26 (3.23) 5.29 (5.26) b 3.70 (4.53) a 2.59 (3.70) a F(3370) = 8.38⁎⁎⁎ .064
(n = 19) (n = 92) (n = 155) (n = 96)
DISCY CD 6.21 (3.66) b 9.10 (4.85) c 3.64 (3.49) a 2.72 (2.88) a F(3357) = 51.34⁎⁎⁎ .301
DISCY ODD 6.68 (2.69) c 8.18 (2.67) c 5.51 (2.61) b 4.41 (2.65) a F(3357) = 37.43⁎⁎⁎ .239
(n = 19) (n = 90) (n = 153) (n = 101)
DISCP CD 6.58 (3.42) b 7.10 (3.83) b 2.44 (2.81) a 2.78 (3.11) a F(3358) = 45.18⁎⁎⁎ .275
DISCP ODD 9.32 (2.58) b 9.36 (2.44) b 6.35 (3.21) a 6.16 (3.48) a F(3358) = 26.79⁎⁎⁎ .183
(n = 13) (n = 73) (n = 124) (n = 80)
MASC 58.38 (19.38) 52.18 (13.29) 55.61 (13.35) 58.06 (16.12) F(3285) = 2.07 .021
(n = 13) (n = 73) (n = 129) (n = 81)
BDI-II 20.08 (16.00) 23.53 (13.46) 27.18 (13.78) b 23.14 (14.13) a F(3291) = 2.78⁎ .028
YSR = Youth Self-Report: Total Problems, Externalizing, Internalizing; CBCL = Child Behavior Checklist: Total Problems, Externalizing, Internalizing;
Aggression measured with the Peer Conflict Scale: Proactive-Overt Aggression Subscale, Proactive-Relational Aggression Subscale, Reactive-Overt Aggression
Subscale, and Reactive-Relational Aggression Subscale; DISC = Diagnostic Interview Schedule for Children (youth and parent report): CD = Conduct Disorder,
number of symptoms, ODD = Oppositional Defiant Disorder, number of symptoms; MASC = Multidimensional Anxiety Scale for Children; BDI-II = Beck
Depression Inventory-II. In parallel analyses conducted without controlling for the effects of gender, there were no significant differences between groups on BDI-II.
⁎⁎⁎ p b .001.
⁎⁎ p b .01.
⁎ p b .05.
a
p b .05 Bonferroni from.
b
p b .05 Bonferroni from.
c
Bonferroni corrections were based on 6 total pairwise comparisons resulting in a critical p value of .008 (.05/6).

determine that there were no differences (F(3381) = .449,
p = .718). The diagnostic group membership variable was
entered as the between subjects variable, with the outcome
variable (e.g. YSR internalizing score) at admission and
discharge as the within subjects variable, and gender as a
covariate. As shown in Table 5, group sizes declined relative to
the group sizes used in our cross-sectional analyses due to
attrition, deeming these analyses purely exploratory. There
were significant between subjects effects found for YSR Total
Problems (small effect size; ηp2 = .032) and Externalizing
scores (large effect size; ηp2 = .169) and all PCS-Y subscale
scores (medium sized effects; ηp2 = .055–.118). Specifically,
post-hoc analyses (Bonferroni) revealed that the CD + CU
group did not differ from the CD group on any of the measures;
however, it differed from the CU and control groups on YSR
Externalizing and from just the control group on
proactive-overt and proactive-relational aggression. The CD
group differed from the CU and/or control groups on YSR
Total Problems and Externalizing and overt aggression
(proactive and reactive). The CD only and CU only groups
scored similarly on relational aggression (proactive and
reactive), which was higher than the psychiatric control group.
3.7. Group comparisons of changes in psychiatric problems
between admission and discharge utilizing the ICU
A series of repeated measures ANCOVAs were conducted
to assess differences in means of psychiatric problems across
admission and discharge for the four diagnostic groups
categorized using the ICU and are displayed in Table 6.
Again, length of stay was compared across groups to
determine that there were no differences (F(3374) = .424,
p = .736). Group membership was entered as the between
subjects variable, with each outcome variable (e.g. YSR
internalizing score) as the within subjects variable and gender
entered as a covariate. Group sizes declined due to attrition,
deeming these analyses purely exploratory. We found
significant between-subjects effects for all variables except
for YSR Internalizing and MASC suggesting that groups
differed significantly in the rate of symptoms change from
admission to discharge. Small effect sizes (ηp2 = .034–.053)
were found for BDI-II and proactive-relational aggression;
medium effect sizes (ηp2 = .078–.109) were found for
reactive-relational aggression, proactive-overt aggression,
and YSR Total Problems; and large effect sizes (ηp2 =
126 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131

Table 5
Repeated Measures ANOVA with Psychiatric Symptoms as Within-Subjects Variables and Group Membership as Between-Subjects Variable Controlling for
the Effects of Gender as Operationalized with APSD.
CD only CD + CU CU only Control
Test statistic
Admission Discharge Admission Discharge Admission Discharge Admission Discharge
(n = 69) (n = 18) (n = 26) (n = 180)
b F(3288) = 3.21⁎
YSR Total 67.38 (8.73) 62.00 (10.88) 63.94 (13.72) 61.67 (15.46) 64.69 (10.78) 60.58 (11.94) 63.44 (9.78)a 58.08 (11.49)
ηp2 = .032
F(3288) = 19.55⁎⁎⁎
YSR Ext 68.46 (8.07)b 63.39 (10.06) 63.33 (12.13)b 63.11 (12.50) 61.54 (9.86)a 58.69 (10.23) 58.37 (9.58)a 54.24 (10.66)
ηp2 = .169
F(3288) = .496
YSR Int 63.28 (11.22) 58.46 (12.46) 61.44 (14.73) 57.44 (17.16) 65.15 (1249) 60.73 (13.65) 65.15 (12.03) 59.33 (12.94)
ηp2 = .005
(n = 71) (n = 17) (n = 26) (n = 171)
b b F(3280) = 7.77⁎⁎⁎
Proact-Overt 3.23 (3.98) 2.83 (3.75) 2.94 (5.41) 3.71 (5.53) 2.58 (4.58) 2.31 (4.89) 1.20 (2.55) a .99 (2.59)
ηp2 = .077
F(3280) = 6.61⁎⁎⁎
Proact-Relat 2.83 (4.13) b 2.77 (3.77) 3.29 (6.73) b 4.53 (7.43) 4.19 (6.69) b 3.46 (6.43) 1.60 (3.04) a
1.36 (2.31)
ηp2 = .066
F(3280) = 12.53⁎⁎⁎
React-Overt 7.14 (6.46) b 5.35 (6.52) 5.94 (7.01) 5.96 (5.15) 3.15 (4.75) a 2.31 (4.52) 3.09 (4.59) a
2.24 (4.02)
ηp2 = .118
F(3280) = 8.09⁎⁎⁎
React-Relat 5.04 (4.54) b 4.49 (4.18) 5.06 (6.01) 5.12 (7.04) 5.96 (7.46) b 4.15 (5.79) 2.90 (3.68) a
2.56 (3.67)
ηp2 = .080
(n = 57) (n = 15) (n = 17) (n = 156)
F(3240) = 1.44
MASC 54.09 (14.17) 53.04 (13.54) 50.27 (17.40) 49.20 (13.06) 49.76 (16.24) 50.35 (17.86) 57.54 (13.90) 53.73 (14.57)
ηp2 = .018
(n = 58) (n = 15) (n = 18) (n = 154)
F(3240) = .594
BDI-II 22.29 (12.99) 14.31 (13.45) 26.33 (14.05) 19.40 (16.23) 23.28 (10.92) 17.17 (11.40) 26.30 (14.19) 17.49 (14.55)
ηp2 = .007
YSR = Youth Self-Report: Total Problems, Externalizing, Internalizing; Aggression measured with the Peer Conflict Scale: Proactive-Overt Aggression
Subscale, Proactive-Relational Aggression Subscale, Reactive-Overt Aggression Subscale, and Reactive-Relational Aggression Subscale; DISC = Diagnostic
Interview Schedule for Children (youth and parent report): CD = Conduct Disorder, number of symptoms, ODD = Oppositional Defiant Disorder, number of
symptoms; MASC = Multidimensional Anxiety Scale for Children; BDI-II = Beck Depression Inventory-II. In parallel analyses conducted without controlling
for the effects of gender, the CU only group was significantly higher than the Control group on Proactive-Overt aggression, but not significantly different from
the two CD groups.
⁎⁎⁎ p b .001.
⁎ p b .05.
a
p b .05 Bonferroni from.
b
Bonferroni corrections were based on 6 total pairwise comparisons resulting in a critical p value of .008 (.05/6).

.167–.248) were found for YSR Externalizing and reactive-
overt aggression. Specifically, post-hoc analyses (Bonferroni)
revealed that psychiatric controls scored lowest compared to
all groups on YSR Externalizing. Psychiatric controls scored
comparably to the CD only group on YSR Total Problems,
which was lower than the CD + CU and CU only group. On
YSR Total Problems and Externalizing and overt aggression
(proactive and reactive), the CD + CU group scored highest of
all groups; however on relational aggression (proactive and
reactive), their scores were not significantly greater than the
CD only group. Interestingly, the CD + CU group scored
similarly to the CU only group on YSR Total Problems, which
was higher than the psychiatric control group.
4. Discussion
Given the inclusion of the ‘with limited prosocial emotions’
specifier in the DSM-5, the present study sought to investigate
the clinical utility of this new addition by exploring and
comparing the prevalence of various psychiatric problems
across four diagnostic groups in an inpatient sample of
adolescents. Additionally, we compared two methods for
operationalizing the specifier based on previous literature.
Several findings merit discussion. First, as expected, there were
significant differences in psychiatric problems across the four
diagnostic groups with lower rates of anxiety disorder diagnosis
and greater externalizing symptoms and rates of aggression
characteristic of the CD + CU group compared to the CD
group. Second, discrepant findings emerged depending on
which measure was used to operationalize the specifier. Finally,
differences in the rate of symptom reduction were found, with
the lowest rate demonstrated by the specifier group.
When examining cross-sectional differences between
groups defined using the APSD, there were no significant
differences between patients with CD with or without the CU
specifier. However, these two groups differed significantly
from the CU only and psychiatric control groups on a variety
of self- and parent-rated measures of externalizing problems.
Interestingly, there were no significant differences on any
broad or narrowband measures of internalizing problems;
however, the CD + CU group had a lower than expected rate
 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131 127

Table 6
Results of a Repeated Measures ANOVA with Psychiatric Symptoms as Within-Subjects Variables and Group Membership as Between-Subjects Variable as
Operationalized with ICU Controlling for the Effects of Gender as Operationalized with APSD.
CD only CD + CU CU only Control
Test statistic
Admission Discharge Admission Discharge Admission Discharge Admission Discharge
(n = 12) (n = 75) (n = 118) (n = 87)
b b F(3287) = 8.29⁎⁎⁎
YSR Total 64.25 (15.80) 52.58 (14.07) 67.05 (8.80) 63.43 (10.86) 65.30 (9.28) 60.02 (11.65) 61.14 (10.19)a 56.05 (11.07)
ηp2 = .080
F(3287) = 31.56⁎⁎⁎
YSR Ext 63.50 (12.78)b 55.00 (11.35) 68.03 (8.46) c 64.67 (9.84) 61.26 (8.88) b 57.64 (9.91) 55.25 (9.59) a 50.83 (10.50)
ηp2 = .248
F(3287) = 2.25
YSR Int 62.42 (16.28) 48.00 (15.63) 62.97 (11.26) 58.89 (12.43) 66.22 (11.28) 60.32 (13.62) 63.61 (12.98) 58.32 (12.16) 2
ηp = .023
(n = 14) (n = 74) (n = 115) (n = 82)
F(3280) = 11.45⁎⁎⁎
Proact-Overt 1.00 (1.62) a .64 (1.34) 3.58 (4.48) b 3.45 (4.33) 1.89 (3.51) a 1.53 (3.63) .68 (1.59) a .65 (1.72)
ηp2 = .109
b a F(3280) = 5.23⁎⁎
Proact-Relat 1.86 (2.88) 1.00 (1.80) 3.12 (4.95) 3.51 (4.97) 2.37 (3.95) 2.03 (3.78) 1.33 (3.54) 1.09 (2.13)
ηp2 = .053
F(3280) = 18.65⁎⁎⁎
React-Overt 2.71 (3.12) a 1.50 (2.77) 7.70 (6.74) b
6.66 (5.40) 3.45 (4.90) a
2.57 (4.30) 2.61 (4.13) a
1.79 (3.72)
ηp2 = .167
b a a F(3280) = 7.91⁎⁎⁎
React-Relat 3.71 (3.07) 1.71 (2.09) 5.30 (5.06) 5.16 (5.00) 3.65 (4.76) 3.11 (4.51) 2.82 (3.98) 2.29 (3.22)
ηp2 = .078
(n = 9) (n = 63) (n = 102) (n = 70)
F(3239) = .839
MASC 60.33 (19.31) 46.67 (13.20) 52.29 (14.00) 53.03 (13.39) 55.24 (13.45) 52.55 (14.89) 58.96 (15.34) 54.59 (15.04) 2
ηp = .010
(n = 10) (n = 63) (n = 100) (n = 71)
BDI-II 20.20 (13.61) 10.40 (11.42) 23.59 (13.20) 16.14 (14.40) 27.68 (13.86) 18.98 (15.19) 23.63 (13.76) 15.45 (12.60) F(3239) = 2.79*
ηp2 = .034
YSR = Youth Self-Report: Total Problems, Externalizing, Internalizing; Aggression measured with the Peer Conflict Scale: Proactive-Overt Aggression
Subscale, Proactive-Relational Aggression Subscale, Reactive-Overt Aggression Subscale, and Reactive-Relational Aggression Subscale; DISC = Diagnostic
Interview Schedule for Children (youth and parent report): CD = Conduct Disorder, number of symptoms, ODD = Oppositional Defiant Disorder, number of
symptoms; MASC = Multidimensional Anxiety Scale for Children; BDI-II = Beck Depression Inventory-II. In parallel analyses conducted without controlling
for the effects of gender, the CD group was not significantly different from any groups on YSR-Externalizing. Additionally, groups were not significantly
different from one another on BDI-II with a reduced effect size of ηp2 = .029.
⁎⁎⁎ p b .001.
⁎⁎ p b .01.
⁎ p b .05.
a
p b .01 Bonferroni from.
b
p b .05 Bonferroni from.
c
Bonferroni corrections were based on 6 total pairwise comparisons resulting in a critical p value of .008 (.05/6).

of anxiety disorder diagnoses at the time of admission, which
is in line with the findings of Pardini and colleagues [24].
The lack of group differences between the CD groups on
most measures of internalizing and externalizing is in contrast
to previous literature examining the additive effects of CU
traits on externalizing behavior in youth with CD [5]. One
reason these differences may have emerged is that previous
research tends to take a dimensional approach to measuring
CU traits. Therefore, it is very likely that the categorization of
individuals based on these traits results in poor predictive
power for group differences, which is consistent with a recent
study that compared a categorical versus dimensional
approach to CU traits [58]. However, these findings are also
inconsistent with previous studies conducted in community
samples, which have found that the CU specifier distinguished
between groups on various measures of antisocial outcomes
[22–24]. A question is therefore raised whether lack of
findings are due to sampling characteristics; in fact, null
findings have similarly been demonstrated among other
clinical samples [17,22]. Finally, another potential source of
discrepancy may be that the four items utilized on the APSD
do not adequately capture the conceptualization of the DSM-5
specifier. Previous research has found that the shallow or
deficient affect criterion, as measured with the APSD, may
have low positive predictive power for measuring the CU
construct and may bias classification of the specifier [59]. To
this effect, we utilized a newer measure of CU traits to
similarly distinguish a subset of conduct disordered patients.
In our second set of cross-sectional analyses, we utilized
the ICU following a method used by Kimonis and colleagues
[43] that best discriminated detained youth. The rationale for
using this method was due to the high severity of clinical
problems in our sample compared to community samples.
Despite this, this method seemed to over identify youth with
the CU specifier, therefore the following findings must be
interpreted with caution. We found that the group of patients
with CD + CU scored significantly (moderate to high
magnitude of effects) higher only on two measures of
overt aggression: proactive and reactive. This finding is in
line with other research showing that CU traits are uniquely
128 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131
associated with overt aggression [60], which suggests that
using the ICU allowed a more fine grained discrimination in
the type of antisocial behaviors youth may be perpetrating.
While we found no differences between groups on
broadband measures of internalizing or a narrowband
anxiety measure, the CD + CU group had a lower than
expected rate of anxiety disorder diagnoses at admission.
Additionally, the ICU discriminated between youth without
CD, but with and without CU (CU only and control group)
on depression. Specifically, our results suggest that those
with high levels of CU traits without a diagnosis of CD may
be at greater risk for experiencing depressive symptoms. In
this set of analyses, cell size for the CD only group was low,
so it is unclear how this contributed to our lack of findings.
Lack of findings could also be attributed to the fact that our
study was conducted in a sample of highly severe inpatient
adolescents. Therefore, levels of psychiatric problems were
high across groups despite diagnostic category. In regard to
our negative findings of group differences in internalizing,
depressive, and anxiety symptoms, there are inconsistencies
with previous literature. While previous findings showing
negative relations between CU and anxiety [6,24] as well as
descriptions of CU as representing a fearless temperament
[5,19] would suggest that anxiety may act as a protective factor
for the development of CU traits, other research has identified
subtypes of youth with CU traits with both high and low levels
of anxiety [37,61]. Therefore, CU traits do not exclude the
potential for high levels of anxiety symptoms in youth. In fact,
there are suggestions that the presence of anxiety may actually
distinguish between youth with CD + CU similar to the
primary and secondary subtypes of psychopathy described in
adult research [59].
In analyses of treatment response, we found a similar pattern
as in cross-sectional analyses using the APSD: the CD + CU
and CD groups still scored higher than the CU and control
groups on measures of externalizing at discharge. However, on
some outcomes (relational aggression), the CU groups
responded less to treatment than the group of psychiatric
controls. This suggests that the tendency toward aggression in
patients with CU traits was unaffected by an intensive, inpatient
treatment program regardless of a diagnosis of CD. Previous
research has established that individuals with CU traits are at a
higher risk of offending later in life and that CU traits predict
more violent offenses, with CU traits predicting an additional
25% of variance in future offending above previous delinquent
behavior [62]. The new DSM-5 specifier allows for future
interventions to include these at-risk youth to potentially reduce
levels of aggression within this population. Additionally,
results of this study point to the importance of identifying
groups of youth with significant levels of CU traits even in the
absence of CD and future research should continue to explore
the characteristics and treatment needs of this group.
When looking at treatment response with diagnostic groups
categorized using the ICU, we found that the CD + CU group
decreased at a lesser rate on a variety of self-reported outcomes
when compared to youth with CD alone. In contrast to findings
when using the APSD, the CU group significantly differed
from psychiatric controls in their treatment response. These
findings are in line with previous treatment outcomes studies
which have shown that youth with CD and high levels of CU
traits respond less to non-specialized treatment programs, with
moderate treatment response of parent-reported CU traits to a
specialized treatment program (Multisystemic Therapy) [60].
While the treatment program completed by our sample
included intensive psychopharmacologic and psychothera-
peutic interventions (individual and family therapy twice per
week) in the context of a therapeutic milieu, the treatment
program was not tailored specifically toward antisocial youth.
Additionally, due to the transdiagnostic and flexible nature of
the unit (clinicians are trained in diverse theoretical orienta-
tions) and the fact that no systematic data are collected on
treatment approaches used with different patients, it was not
possible to determine whether group differences were due to
differences in treatment approaches used by clinicians. These
results should be interpreted with caution as our sample had
high levels of attrition at the end of treatment and therefore
should be replicated with larger samples.
Overall, using the ICU appeared to yield stronger differences
in associated outcomes between youth with CD compared to the
APSD. This is congruent with a recent study that evaluated the
predictive value of several different measures of CU traits in
youth for antisocial behavior [63]. It was found that the ICU,
relative to the APSD, YPI, and CPS (Childhood Psychopathy
Scale) [64] demonstrated higher internal consistency, its
Callousness subscale was superior in predicting variance in
aggression, and its Uncaring subscale was the only unique
predictor of delinquency. In the current study, the APSD had
low internal consistency. While the ICU performed better
in distinguishing between CD and CD + CU groups on
hypothesized outcomes, this may be a function of the improved
psychometric properties or the inclusion of a greater number of
items (and subsequently greater power) used to measure the
specifier; however, there were still limitations in its use.
Specifically, there were null findings in regard to differences
between the CD youth with and without the CU specifier on the
basis of internalizing symptoms and treatment response.
Therefore, more work is needed to refine existing assessment
measures and develop new measures that can appropriately
operationalize the new specifier.
Additionally, conclusions made by the differential
findings when using the ICU versus the APSD are tempered
since this method of classification has not been replicated in
other clinical samples. In fact, the method of classification
for the ICU was found to best discriminate incarcerated
youth in one previous study; however, in the same study, it
was found that using a smaller set of items with a more
stringent cutoff was found to best discriminate community
youth [55]. Therefore, when categorizing the ICU using a
less stringent cutoff for each item and a greater number of
items to represent the specifier used in this study may
account for the possible over diagnosis of CU traits — as
suggested by an increase from 6.5% (using the APSD) to
 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131
24.1% (using the ICU) prevalence in the sample. The greater
number of items used for the ICU compared to the APSD
also likely contributed to the improvement in internal
consistency in the ICU compared to the APSD. In fact,
convergent classification was only fair between these two
methods as measured with the kappa statistic (.251). It is
possible that the larger group sizes for the CU specifier
(CD + CU) group resulted in higher power to detect group
differences. While the study design makes it impossible to
determine which of these methods is more appropriately
measuring CU traits as they are operationalized in the
DSM-5, the conclusions drawn from the present findings
should remain speculative given the significant methodological
differences in operationalizing the specifier. In examining the
differences between the items used in the APSD and ICU for our
CU specifier scale, the additional items used in our 8-item set
with the ICU include “I express my feelings openly”, “I always
try my best”, “I apologize to persons I hurt”, “I try not to hurt
others' feelings”, and “I do things to make others feel good”.
These items mostly capture the interpersonal side of CU traits
and likely contributed to the stronger predictive validity of not
only more overt aggression, specifically, but also the levels of
broad externalizing traits compared to the APSD. More research
is necessary to determine the optimal cut-off of and number of
items endorsed for each specifier criterion using ICU items.
Additionally, while our methodology utilized multiple infor-
mants for a diagnosis of CD and on the APSD, we did not
collect a parent-report version of the ICU, increasing the
likelihood of shared method variance as all post-treatment
outcome measures were self-report questionnaires. The DSM-5
specifies that in order to meet criteria for the specifier, the
symptoms must be present in a variety of settings, which was
another limitation of our use of only a self-report ICU.
Therefore, these symptoms should be assessed by multiple
informants. Because the APSD items did not reliably
demonstrate clinical utility in this or the two previous studies
using clinical samples, and more work is needed for the ICU to
be viable alternative, it is clear that more research should focus
on developing user friendly instruments with discriminative
validity among clinical samples of adolescents based on the
presence of the CU specifier.
Given the lack of expected findings in this study as well as
previous studies in clinical and incarcerated samples
[17,21,22,30], it is possible that the CU specifier as assessed
with current measures is capturing general psychopathology,
rather than a construct unique among CD youth. A second
possibility is that among highly severe samples, this construct
cannot be distinguished using self-report measures. Alterna-
tively, and more likely, is that CU traits are best represented as
a dimensional construct among youth, rather than categorical
[65]. The research base from which the DSM-5 specifier was
developed from has relied solely on dimensional measures of
CU traits. Additionally, CU traits in youth have been likened to
psychopathy, which is a pattern of behaviors represented in the
diagnosis of antisocial personality disorder. In line with the
definition of a personality disorder in the DSM [4], CU traits
129
have been demonstrated to be enduring, pervasive, with early
onset, stable over time, and leading to distress and impairment
[5]. CU traits represent a unique developmental pathway in
youth, even when they do not occur with a diagnosis of CD
[66]. As the DSM moves toward a dimensional framework for
categorizing disorders, and especially personality disorders as
represented in Section 3, it is likely that CU traits best fit within
the personality disorder area of nosology. However, given that
our current nosological system continues to utilize discrete
categories, which are strong determinants of the services and
care received by individuals, it is imperative that research
critically evaluate our current measurement tools among
patient samples to determine whether they adequately capture
the disorders described in the DSM.
Another important point of discussion is the legal
implications of the new DSM-5 specifier, particularly in
regard to stigmatization of this label. While literature on the
label “with limited prosocial emotions” is limited, there is
research testing the consequences of the label “psychopathic
traits” as applied to youth, due to specific concerns that use of
this label may lead to negative bias in the legal system at the
expense of youth [67]. Specifically, it seems that there are
moderate negative effects on legal decisions by judges and
juries, including beliefs about lack of rehabilitation for youth
exhibiting these traits [65]. While earlier discussion in DSM
development led to proposals to use less stigmatizing names
such as ‘undersocialized’ for the current specifier, it was
determined that the lack of clarity of these options would lead
to variability in the conceptualization and assessment by
treatment providers and researchers. One recent study
examined perceptions by mock jurors of male juvenile
offenders given the DSM-5 specifier. Results demonstrated
that jurors were more likely to rate offenders given the specifier
diagnosis (compared to CD only diagnosis) as a psychopath,
more evil, and posing a risk of violence, with medium effect
sizes [68]. Future research on the DSM-5 specifier must
balance investigations of the validity and measurement with
considerations about the potential stigmatization of youth with
this label.
Results of this study must be interpreted in the context of
some limitations. First, attrition through treatment tempers the
conclusions that can be made about treatment response.
Additionally, the additional use of a parent report measure of
ICU would have been preferred. However, several strengths of
this study must additionally be noted. First, our use of
combined self and parent-rated measures of both CD and CU
traits is in line with previous research showing greater validity
of findings that utilize multiple raters. Our study was also the
first study of the DSM-5 CU specifier to be conducted in an
inpatient clinical sample. All previous studies have been
conducted in either outpatient, community, or incarcerated
samples of youth. Additionally, the outcomes measures we
utilized covered a broad range of both externalizing and
internalizing problems, whereas previous research has tended
to focus solely on antisocial outcomes. Lastly, we included a
group of patients who met criteria for the CU specifier who did
130 S. Vanwoerden et al. / Comprehensive Psychiatry 69 (2016) 116–131
not have a diagnosis of CD and found that this group was
significantly elevated on selected measures. In all, we add to a
small but growing amount of literature testing the utility of the
new CU specifier in distinguishing between youth with and
without CD. It is clear that while the ICU provides a relatively
greater form of predictive validity, the essence of CU traits that
have been demonstrated in prior research does not seem to be
captured with the current measures available in the context of
new DSM-5 criteria.
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