Can Callous-Unemotional Traits be Reliably Measured in Preschoolers?

Transcription

1 J Abnorm Child Psychol DOI /s y Can Callous-Unemotional Traits be Reliably Measured in Preschoolers? Eva R. Kimonis 1 & Kostas A. Fanti 1 & Xenia Anastassiou-Hadjicharalambous 1 & Biran Mertan 1 & Natalie Goulter 1 & Evita Katsimicha 1 # Springer Science+Business Media New York 2015 Abstract Callous-unemotional (CU) traits designate an important subgroup of antisocial individuals at risk for earlystarting, severe, and persistent conduct problems, but this construct has received limited attention among young children. The current study evaluated the factor structure, psychometric properties, and validity of scores on a comprehensive measure of CU traits, the Inventory of Callous-Unemotional Traits (ICU), in relation to measures of antisocial/prosocial behavior and emotional processing, administered to preschool children. The sample included 214 boys (52 %) and girls (48 %, M age = 4.7, SD = 0.69) recruited from mainstream and highrisk preschools. Confirmatory factor analyses supported a two-factor structure including callous and uncaring dimensions from 12 of the 24 original ICU items. Scores on the parent- and teacher-reported ICU were internally consistent andcombinedcuscoresshowedexpectedassociationswith an alternate measure of CU traits and measures of empathy, prosocial behavior, conduct problems, and aggression. Preschool children high on CU traits were less accurate, relative to children scoring low, in recognizing facial expressions. They were also less attentionally engaged by images of others in distress when co-occurring conduct problems presented. Findings extend the literature by supporting the psychometric properties of the ICU among young children, and open several avenues for studying early precursors to this severe personality disturbance. Electronic supplementary material The online version of this article (doi: /s y) contains supplementary material, which is available to authorized users. * Eva R. Kimonis e.kimonis@unsw.edu.au 1 Sydney, Australia Keywords Callous-unemotional traits. Psychopathy. Conduct problems. With limited prosocial emotions. Preschool Introduction A substantial body of research suggests that non-normative levels of callous-unemotional (CU) traits are useful for identifying antisocial children and adolescents exhibiting early starting, severe, chronic and aggressive conduct problems that are underpinned by distinct causal factors (Frick et al. 2014; Viding et al. 2007). For example, CU traits measured at school age predict antisocial and criminal behavior in adulthood, even after controlling for severity and onset of conduct disorder (CD) (McMahon et al. 2010). Further, a notable longitudinal study found that psychopathic traits measured at age 13 were moderately stable to age 24 (r = 0.32), despite different informants and assessment instruments used across the two age periods (Lynam et al. 2007). Although only a minority (14 %) of those who scored in the top 20 % at age 13 went on to warrant an adult diagnosis of psychopathy, estimates suggest that this construct is at least equally stable to other youth disorders (Loeber et al. 2009). As a result, it is critical to identify children with non-normative levels of CU traits early in development to inform preventive interventions. CU traits (i.e., callous/lack of empathy, lack of remorse/ guilt, shallow affect), which capture the emotional detachment dimension of psychopathy in adults, are linked with emotional hyporeactivity to fear- and empathy-evoking stimuli (i.e., pictures, words, facial expressions, vocal tones) (see Marsh and Blair 2008). Similar to adults high on the affective dimension of psychopathy, non-normative CU traits designate groups of antisocial children and adolescents showing reduced amygdala activation while processing fearful expressions (e.g., Viding

2 JAbnormChildPsychol et al. 2012) and reduced startle potentiation to fearful stimuli (Fanti et al. 2015). Youth with CU traits also exhibit lower autonomic activity when viewing images of others in distress (e.g., Blair et al. 2001; Lorber 2004), and are less accurate in recognizing sad and fearful expressions compared with their low psychopathic/cu counterparts (Blair et al. 2001). Schoolaged community children and detained adolescents high on CU traits are less attentively engaged by others distress cues on a dot-probe task when they also score high on aggressive conduct problems (Kimonis et al. 2006b, 2008a). To date, study of emotional deficits among young children with CU traits is limited, which may be in part due to the lack of available tools for measuring preschool CU traits and emotional deficits. Measuring CU Traits in Youth The Inventory of Callous-Unemotional Traits (ICU; Kimonis et al. 2008b) is a promising measure designed to assess CU traits in children and adolescents, and it has been adapted for use with pre-schoolers (Frick 2004). The ICU was systematically developed over two decades, and designed to overcome the limitations of its ancestor, the Antisocial Process Screening Device (APSD; Frick and Hare 2001). With its 24 items it provides one of the most comprehensive measures of CU traits currently available. Prior validation studies found that ICU total scores are internally consistent and manifest expected associations with relevant criterion constructs (e.g., low prosociality and empathy, high conduct problems and aggression, indices of constricted emotion; Essau et al. 2006; Fanti et al. 2009; Kimonis et al. 2008b; Roose et al. 2010), supporting the construct validity of ICU scores in youth. Factor analytic studies in adolescent non-referred (Essau et al. 2006; Fanti et al. 2009; Roose et al. 2010) and detained/incarcerated samples (Kimonis et al. 2008b) suggest that, in addition to a CU factor, the self-report version of the ICU also taps three meaningful dimensions of CU traits that show distinct correlates: uncaring, callousness, and unemotional (i.e., three-factor bifactor model). Across studies, the uncaring factor is associated with empathy deficits, and both uncaring and callousness factors are associated with antisocial behavior, conduct problems, and aggression (Essau et al. 2006; Fanti et al. 2009; Kimonis et al. 2008b; Roose et al. 2010). The unemotional factor generally fails to demonstrate consistent or robust associations with external correlates, except sensation seeking and empathy, which has led some to suggest a need for refining how the ICU operationalizes the shallow affect dimension of CU traits (Hawes et al. 2014a, b; Kimonis et al. 2013, 2014b). The problematic nature of the unemotional scale is reflected in the elimination of all but one of its constituent items (i.e., item 6: BI do not show my emotions to others^) from the best-fitting two-factor models identified for schoolaged samples (Hawes et al. 2014a, b; Houghton et al. 2013, see Table 1). 1 For example, item response theory analysis of parent-reported ICU scores among 6 12 year old clinicreferred boys led to retention of only 12 of the original 24 items, which demonstrated good coverage of the latent CU construct (Hawes et al. 2014a, b). In this model, items mapped on to distinct uncaring and callous dimensions that significantly correlated with measures of conduct problems and oppositional defiant disorder (ODD). Using self-reported ICU scores of 7 12 year old Australian community children, Houghton et al. (2013) found support for an alternative two-factor (uncaring, callousness) model using 16 ICU items, although scores were not validated against external criteria. There has been far less study of the assessment of CU traits and the factor structure of the ICU prior to school age. Preschool CU Traits Despite the emergence of self-conscious emotions and aggressive behavior during the preschool period, research on CU traits among young children is scarce (e.g., Kochanska and Thompson 1997; Shaw et al. 2003). The first study to examine CU traits among preschoolers (N = 49, 2 5 years old) found an association between combined parent- and teacher-reported CU scores on the APSD and teacher-reported proactive and total aggression (Kimonis et al. 2006a). A second study with a community sample of preschoolers (N = 178) found that scores on a proxy measure of CU traits created using 5 items from the Child Behavior Checklist (CBCL) were stable from ages 3 to 5, and associated with fearless temperament and low levels of negative affectivity and heart period reactivity during a still-face paradigm (Willoughby et al. 2011). While the aforementioned study makes an important contribution, it is not clear to what extent this novel operationalization of CU traits maps on to that of more commonly used measures of CU traits given that parent-reported CBCL CU scores were not significantly correlated with teacher-reported ICU scores (rs = ) in a study of preschoolers (Ezpeleta et al. 2013). Only two known studies to date have examined the operationalization of CU traits provided by the ICU with samples of young children. In the first, Ezpeleta et al. (2013) replicated the same three-factor bifactor structure found for adolescent samples using Catalan and Spanish language versions of the teacher-reported ICU with 3 and 4-year-old community children (N = 622). ICU total scores were moderately stable across 1 year (ICC = 0.53), and correlated with teacher- 1 Hawes et al. (2014b) found that the fit of the 2-factor (Callousness, Uncaring) bifactor model (χ2 = 86.57, df = 43, CFI = 0.97, TLI = 0.96, RMSEA = 0.06) was almost identical to that of the correlated two-factor model (χ2 = , df = 53, CFI = 0.97, TLI = 0.96, RMSEA = 0.06), providing support for a general CU factor. They reported on the correlated two-factor model in their study as it provided a more parsimonious model.

3 J Abnorm Child Psychol Table 1 Factor structures of the four models tested Kimonis et al. (2008b) three factor bifactor model (uncaring, callous, unemotional) Hawes et al. (2014a, b) two factor model (uncaring, callous) Houghton et al. (2013) two factor model (uncaring, callous) Willoughby et al. (2015) twofactor model (empathic/ prosocial, CU) 1. Expresses his/her feelings openly. a Unemotional Empathic/prosocial 2. Does not seem to know Bright^ from Bwrong^. CU 3. Seems motivated to do his/her best in Uncaring Uncaring Empathic/prosocial structured activities. a 4. Does not care who he/she hurts to get what Callous Callous Callous CU he/she wants. 5. Feels bad or guilty when he/she has done Uncaring Uncaring Uncaring Empathic/prosocial something wrong. a 6. Does not show emotions. Unemotional Callous CU 7. Does not care about being on time. Callous Callous CU 8. Is concerned about the feelings of others. a Callous Uncaring Callous Empathic/prosocial 9. Does not care if he/she is in trouble. Callous Callous Callous CU 10. Does not let feelings control him/her. Empathic/prosocial 11. Does not care about doing things well. Callous Callous Callous CU 12. Seems very cold and uncaring. Callous Callous Callous CU 13. Easily admits to being wrong. a Uncaring Uncaring Empathic/prosocial 14. It is easy to tell how he/she is feeling. a Unemotional Empathic/prosocial 15. Always tries his/her best. a Uncaring Uncaring Empathic/prosocial 16. Apologizes (Bsay he/she is sorry^) to Uncaring Uncaring Uncaring Empathic/prosocial persons he/she has hurt. a 17. Tries not to hurt others feelings. a Uncaring Uncaring Uncaring Empathic/prosocial 18. Shows no remorse when he/she has Callous Callous Callous CU done something wrong. 19. Is very expressive and emotional. a Unemotional Empathic/prosocial 20. Does not like to put the time into doing Callous CU things well. 21. The feelings of others are unimportant to Callous Callous Callous CU him/her. 22. Hides his/her feelings from others. Unemotional CU 23. Works hard on everything. a Uncaring Uncaring Empathic/prosocial 24. Does things to make others feel good. a Uncaring Uncaring Uncaring Empathic/prosocial a Indicates reverse scored items rated prosocial behavior, executive functions, conduct problems, and verbal, relational and physical aggression. With regard to ICU subscales, uncaring scores were associated with total and nonaggressive conduct problems, and callousness scores with total and aggressive conduct problems, but unemotional scores were unassociated, consistent with studies of older youth (e.g., Kimonis et al. 2008b). Callousness also predicted a disruptive behavior disorder diagnosis (ODD or CD) and high global functional impairment 1 year later. In the second study, Willoughby et al. (2015) examined parent-reported ICU scores among first grade students (M age = 7.3, SD = 0.3). They found support for a two-factor model using all 24 items and comprising empathic-prosocial and CU factors that were both moderately to strongly correlated with ODD/CD scores (Willoughby et al. 2015). These findings provide preliminary support that CU traits may be reliably and validly measured in young children using the ICU, and indicate poor prognosis. Inconsistencies in factor structure across studies may reflect variability in the developmental periods examined and/or the reporter (teacher v. parent) used. There are at least three critical next steps towards further validating the ICU for use with young children and gaining clarity into its optimal factor structure. The first is to compare factor structures identified in prior studies within a preschool sample. The second is to employ a multi-method assessment of CU traits to prevent against the possibility of inflated associations due to shared method variance correlations were only significant when the same reporter rated the ICU and criterion measures (Ezpeleta et al. 2013). The third is to include measures of emotional functioning, which constitute a core deficit of CU and psychopathic traits (Cleckley 1941).

4 JAbnormChildPsychol The majority of prior studies testing the validity of ICU scores in pre-schoolers used behavioral measures, and failed to consider emotional deficits core to psychopathic traits. For example, among school-aged boys (N = 55), high selfreported ICU total scores were associated with a poor ability to recognize fearful faces and body postures (Muñoz 2009). Further, ICU scores were associated with deficits in the processing of distress stimuli in a sample of detained adolescent boys (N = 88) (Kimonis et al. 2008a, b). To date, very little is known about whether scores on the ICU among children under age six are associated with core deficits in emotional functioning, which the present study aimed to elucidate. Present Study The vast majority of prior studies of the ICU focus on adolescent samples, use self-report, and fail to include laboratory measures of emotional processing that are core to CU traits. The present study aimed to address these gaps by testing the factor structure comparing alternative models supported by past research, testing the reliability and validity of parent- and teacher-report scores on the preschool version of the ICU, and testing the association between ICU scores and a battery of measures assessing emotional processing, among a sample of young children. There were three primary motivations for pursuing this objective. First, it provides a means for identifying very young children who may be at heightened risk for severe, lifelong impairment to administer preventive interventions. Second, it permits the assessment of change in CU traits in response to such interventions, and may also be used in longitudinal research to inform the stability of CU traits from early childhood. Third, it has the potential to inform developmental theory by permitting the examination of theoretically relevant criterion measures, such as deficient processing of emotion, to establish parallels to theory-based research conducted with older children and adults. The validity of ICU scores was examined in the form of (1) convergent validity in relation to an alternative measure of CU traits, empathy and prosocial behavior scores, (2) discriminant validity in relation to anxiety scores, and concurrent validity in relation to (3) antisocial behavior, aggression, and psychopathy-linked narcissism and impulsivity, as well as (4) emotional processing on laboratory tasks. In accordance with research conducted with older samples, it was hypothesized that children rated high on the ICU by parents and teachers would score high on an alternate measure of CU traits, low on total, cognitive and affective empathy, and high on conduct problems, aggression, and psychopathy-linked narcissism and impulsivity. It was also hypothesized that preschoolers scoring high on the ICU would be less accurate in recognizing fearful and sad static and dynamic facial expressions, and that those also scoring high on conduct problems would be less attentively engaged by images of others in distress, consistent with prior research with older youth (Kimonis et al. 2006b, 2008a). Method Participants There is evidence to suggest that samples combining both community and high-risk youth yield the strongest effect sizes with respect to associations with external correlates (Asscher et al. 2011). In order to recruit both high-risk and healthy community children, participants were recruited from both mainstream (n = 169) and high-risk (n = 45) preschools (N = 214). 2 This method achieved the goal of recruiting a sample with more variability in CU traits; high-risk children, relative to children recruited from mainstream preschools, were rated higher on total CU traits (M =34.47,SD = v. M =26.15,SD = 11.25, t(211) = 4.43, p < 0.001), their mothers attained lower educational achievement (22.5 % never finished high school relative to 9.4 % of community mothers), and the average family income was lower (high-risk sample, 16,771 Euros [SD = 10,263] v. community sample, 30,528 Euros [SD = 14,595]). Children ranged in age from 3 to 6 years (M age = 4.7, SD = 0.69) and their parents ranged in agefrom22to53years(m age = 33.6, SD = 4.8). The sample was roughly equally divided between boys (n = 109) and girls (n = 100), however, five families did not report on their child s sex. Across samples, the majority of parents were married (80.6 %). Procedure The Cyprus Ministry of Education and a University Institutional Review Board approved all study procedures. Study approval was also secured from school headmasters. Parents provided informed consent. Parents and/or teachers completed questionnaires about the child, and trained research staff individually administered laboratory tasks to children alone in a quiet room in their schools to assess emotional functioning. A total of 180 parents and 204 teachers completed study measures, such that the majority of children had scores from multiple raters. Families were compensated for their participation with a small toy for the child. 2 The high-risk preschool was operated by a non-profit organization whose aim is to strengthen vulnerable families and the Bworking poor^ by providing essential educational, nutritional, and health support. Twelve children from the high-risk preschool resided in an on-campus group home following removal from their home or were classified by social services as being in need of services (i.e., family empowerment project) due to low socioeconomic status.

5 J Abnorm Child Psychol Measures Multiple measures were included in this study to examine the convergent (UNSW CU scale, Griffith Empathy Measure), discriminant (SDQ), and concurrent (Eyberg Child Behavior Inventory, Preschool Social Behavior Scale, APSD, static and dynamic faces tasks, dot-probe task) validity of ICU scores. Callous-Unemotional Traits CU traits were assessed using the 24-item preschool version of the Inventory of Callous- Unemotional Traits (ICU; Frick 2004). Parents and teachers rated children on a four point Likert scale (0 = Not at all true, 1 = Somewhat true,2 = Very true,3 = Definitely true) with total scores ranging from 0 to 72. ICU scores show acceptable internal consistency and correlate with important outcomes, such as reduced emotional responding to distress cues and severe aggression, across a wide age range, sex, types of samples, and different language translations (e.g., Ezpeleta et al. 2013;Fanti et al. 2009). Parent and teacher scores were combined in a conservative fashion by taking the higher rating between raters (i.e., resolved score). This method is beneficial for circumventing potential underreporting (e.g., Pardini et al. 2007). Studies that combine multiple informants in this way report similar results to those using different procedures (Piacentini et al. 1992). The intraclass correlation for average measures between parent and teacher ICU scores was 0.48, p < 0.001, and they were moderately correlated (rs 0.24, p = to 0.40, p <0.001). UNSW CU Scale The University of New South Wales (UNSW) CU scale was developed by Dadds et al. (2005), and comprises joint items from the Antisocial Process Screening Device (APSD; Frick and Hare 2001) andthe Strengths and Difficulties Questionnaire (SDQ; Goodman 1997). The UNSW CU scale has been extensively described and validated in previous research on CU traits in children (Dadds et al. 2005, 2006, 2009). Scores have demonstrated acceptable to good internal consistency across multiple informants in prior studies (αs ranging from ; e.g., Hawes et al. 2013), but were marginal (α = 0.67) in the present study. Empathy Empathy was measured using the 23-item Griffith Empathy Measure (GEM; Dadds et al. 2008a), in which parents rate each item on a nine-point Likert scale from strongly disagree ( 4) to strongly agree (+4). Items include cognitive (e.g., Bmy child has trouble understanding other people s feelings^) and affective (e.g., Bseeing another child sad makes my child feel sad^) indicators of empathy. Prior studies have demonstrated good test-retest reliability of scores over 1 week (r > 0.89) and 6 month intervals (r > 0.69), good internal consistencies, a stable factor structure across age and sex groups, inter-parental agreement (r > 0.47), and convergence with child reports (r = 0.41) (Dadds et al. 2008b). In the present study, total GEM (αs = ) and affective scale scores demonstrated adequate reliability (αs = ), however, cognitive scale scores did not (αs = ). Child Social, Emotional and Behavioral Problems Prosocial behavior and anxiety were assessed using the 25- item parent-reported Strengths and Difficulties Questionnaire (SDQ; Goodman 1997). The SDQ is composed of five subscales; Prosocial Behavior, Emotional Symptoms (anxiety), Peer Problems, Hyperactivity and Conduct Problems (latter three not used). Parents indicate whether each item is Bnot true^, Bsomewhat true^, or Bcertainly true^ about their child. Prior research with clinic and community samples supports the psychometric properties of SDQ scores with coefficient alphas across subscales ranging from 0.60 to 0.80, and convergence with independent measures demonstrating sound validity (Hawes and Dadds 2007). In the present study, internal consistencies were low for prosocial behavior (α = ) and anxiety (α = ) scores. Conduct Problems The Eyberg Child Behavior Inventory (ECBI; Eyberg and Pincus 1999) is a 36-item parent-rating scale of child conduct problems. Parents indicate the intensity of the child s behaviors on a 7-point scale (from 1 Bnever^ to 7 Balways^), as well as whether he/she perceives the behavior to be a current problem (not included). The Intensity score has a possible range between 36 and 252, and has demonstrated excellent internal consistency (α = 0.95, Eyberg and Pincus 1999), interrater (mother-father) reliability (0.69, Eisenstadt et al. 1994), and test-retest reliability across 12 weeks (0.80) and 10 months (0.75, Funderburk et al. 2003). In the present study, total Intensity scores showed excellent internal consistency (α = 0.94). The 38-item Sutter-Eyberg Student Behavior Inventory-Revised (SESBI-R; Sutter and Eyberg 1984) is a teacher adaptation of the ECBI, and similarly computes intensity and problem (not used) scales. SESBI scores have demonstrated high internal consistency, inter-teacher agreement, and test-retest reliability (Funderburk and Eyberg 1989). In the present study, SESBI-R Intensity total scores demonstrated excellent internal consistency (α = 0.97). ECBI and SESBI-R scores were combined using resolved T-scores. Aggression Child relational and overt aggression, and teacher-reported prosocial behavior were assessed with the Preschool Social Behavior Scale Teacher Form (PSBS-T; Crick et al. 1997). This version was adapted from the Children s Social Behavior Scale Teacher Form (CSBS-T; Crick 1996) for use with young children. The PSBS-T is a 25- item inventory, with six subscales assessing relational aggression (8 items; αs = ), overt/physical aggression (8 items; αs = ), prosocial behavior (4 items; α = ), depressed affect (3 items; α = ),

6 JAbnormChildPsychol and child s acceptance by same sex and opposite sex peers (latter two not included). Teachers rated items on a 5-point Likert scale ranging from 1 ( never or almost never true ) to 5( always or almost always true ), and scores were summed across subscales. Psychopathy-Linked Narcissism and Impulsivity Parents and teachers completed the APSD that uses items similar in content to those of the Psychopathy Checklist- Revised (PCL-R; Hare 1991), but with developmentally appropriate modifications for child samples (Frick and Hare 2001). The 7-item narcissism and 9-item impulsivity resolved scores, combining parent and teacher reports, were used for the purposes of the present study (Frick et al. 2000; Vitacco et al. 2003). Internal consistency was marginal for resolved narcissism scores (α = 0.64) and acceptable for resolved impulsivity scores (α =0.75). Emotional Processing Three tasks were used to assess emotional processing, as indexed by emotional recognition and attentional orienting to negative emotion. The Ekman Emotional Expression Task (Blair et al. 2001) was used to assess emotion recognition, following modification for use with preschool children through an iterative pilot testing process. The stimuli used are taken from the empirically valid and reliable Pictures of Facial Affect Series (Ekman and Friesen 1976). The original Ekman picture set contains examples of both men and womenexpressingthesixbasicemotionalfacialexpressions that Ekman argued are universally recognizable and have been consistently recognised by people from widely differing cultures: anger, disgust, fear, happiness, sadness, and surprise. For this preschool sample, only prototypical expressions (i.e., 100 % expression) were used, as opposed to the morphed images created by Blair et al. (2001), and disgust and surprise categories were removed because of their complexity. Following a 500 ms fixation cross, each face was presented one at a time to the child on a computer screen for 1000 ms. The child was instructed to identify the emotion out loud and a research assistant entered the child s response on a keyboard using designated keys. After a practice phase consisting of each of the four expressions, participants were presented with 40 test stimuli in random order. Thus, for each of the four emotions, there were ten stimuli faces. Participants were scored according to whether or not they correctly identified the facial expression depicted, which was averaged across each of the four emotion categories. A dynamic version of the above-described emotion recognition task was created using standardized stimuli of dynamic, prototypical facial expressions from the Montréal Pain and Affective Face Clips (MPAFC) database (see Simon et al. 2006). Participants viewed a series of 40 1-s dynamic visual stimuli depicting a man or woman (20 of each sex) whose facial expression morphed from neutral to one of five expressions: anger, fear, happiness, sadness, and pain. Eight clips were presented in random order for each emotion. Children viewed video clips on a computer screen and were told to label each emotion aloud. Researchers recorded the child s response with a designated key press on a keyboard. Participants were scored according to whether or not they correctly identified the facial expression depicted. 3 Attentional Orienting to Distress The dot-probe task is a common laboratory paradigm used to index attentional bias for emotional stimuli at early stages of information processing (MacLeod et al. 1986). It provides a quick, convenient, and inexpensive index of emotional responsiveness. The task is typically modified in terms of specific emotional content based on the focus of a given investigation, in this case the relationship between emotional processing of distress cues and CU traits. The emotional pictures version of the task presents a series of picture pairs of distressing (e.g., crying child) and neutral (e.g., book) emotional content using slides primarily taken from the International Affective Picture System (IAPS; Lang et al. 1997). Slides were selected based on their use in previous studies with children to tap distress content domains (Blair 1999; McManis et al. 2001), and were deemed appropriate for young children by a team of researchers. The version of the task used in the present study was modified for use with preschoolers through an iterative pilot testing process, which ultimately resulted in a brief version of the task in which fixation crosses and probes were replaced with cartoon images. This preschool version of the task consisted of 1 block of practice stimuli (8 picture pairs) followed by 3 experimental blocks, each containing 8 picture pairs. Each picture presentation consisted of three sequential components: (1) a 500 millisecond cartoon image of Jerry the mouse (i.e., fixation cross) appearing in the center of the screen, (2) a 500 millisecond simultaneous presentation of one of two potential picture pairings: neutral-neutral and distress-neutral, with stimuli centered and located immediately above and below the 3 All analyses were repeated covarying sample, age, and sex. Results remained largely unchanged across primary study variables, with the exception of recognition of happy faces that reduced to nonsignificance (see note in Table 4).

7 J Abnorm Child Psychol location of the fixation cross, and (3) a second cartoon image of cheese (i.e., dot-probe) appearing in either the top or bottom picture location. Children were instructed to help Jerry find his cheese, and on every trial, he or she had to select a key on the keyboard that corresponded to the location on the screen (up or down) where the dot-probe appeared. If no key was pressed within 5000 milliseconds, the response was recorded as incorrect. The number and location of picture stimuli were counterbalanced across test trials in order to ensure that an equal number of emotional and neutral stimuli appeared in both top and bottom locations. Additionally, there were an equal number of emotional and neutral stimuli that were replaced versus not replaced by a dot-probe stimulus. The primary dependent measure for the current study was an attentional facilitation index. This facilitation index was calculated by subtracting the average response time (latency) to dotprobes replacing distressing pictures in distress-neutral picture pairs from the average latency to probes replacing neutral stimuli in the various neutral-neutral picture pairs. To control for potential location effects, such as an attentional preference for the top or bottom location of the screen, the following formula was used to calculate the facilitation indices that only compared neutral and emotional probes in the same location: Facilitation =1/2 x [(Neutral Only/Dot-probe Up - Distress Up/Dot-probe Up) + (Neutral Only/Dot-probe Down - Distress Down/Dot-probe Down)]. Consistent with prior uses of the task (Kimonis et al. 2008a), incorrect responses and response times less than 100 milliseconds were not included in the calculation of facilitation indices. Facilitation scores greater than three standard deviations above or below the mean were truncated to 3 SDs. Given that emotional pictures typically facilitate allocation of attention, participants were generally expected to respond more quickly to probes replacing emotional images because these slides capture their initial attention, resulting in a positive facilitation index. Results Confirmatory Factor Analyses Confirmatory factor analyses (CFA) were estimated using resolved ICU scores in Mplus 7.3 (Muthén & Muthén, ) to compare the fit of four alternative factor models: 22-item three-factor bifactor (e.g., Kimonis et al. 2008b); Hawes et al. (2014b) correlated two-factor (12 items); Willoughby et al. (2015) two-factor (24 items), and Houghton et al. (2013) two-factor (16 item) models (see Table 1). Model fit was evaluated using the χ 2 fit statistic, comparative fit index (CFI; Bentler 1990), Tucker- Lewis index (TLI; Tucker and Lewis 1973), root mean square error of approximation (RMSEA), and the Akaike information criterion (AIC; Akaike 1987). A good fit was determined by the minimum AIC value (Schermelleh- Engeletal.2003) and CFI and TLI values above 0.95 (Hu and Bentler 1999). A RMSEA value below 0.05 indicates a very good model, a value of 0.08 indicates adequate fit, and a value above 0.10 indicates poor model fit (Browne and Cudeck 1993). According to these criteria, the results of CFA analyses (see Table 2) revealed that the Hawes et al. (2014b) correlated two-factor model provided the optimal fit. Internal Consistency In the present study, resolved Hawes et al. (2014b) 12-item ICU total scores demonstrated good internal consistency (α = 0.85). The mean inter-item correlation was 0.33, and the mean corrected item-to-total scale correlation was Item-to-total scale correlations >0.30 indicate good discrimination and Cronbach s alpha >0.70 suggests that the item set is internally consistent (Nunnally and Bernstein 1994). Corrected item-to-total scale correlations were >0.30 for all items. Alpha coefficients for subscale scores were good (α =0.80 for uncaring, 0.82 for callousness). Mean inter-item correlations were and 0.37, and mean corrected item-to-total scale correlations were 0.61 and 0.54 for uncaring and callousness subscales, respectively. Convergent and Discriminant Validity Analyses testing associations with criterion measures were conducted for Hawes et al. (2014b) 12-item total 1 and subscale scores; however, correlations for the 24- item ICU total were retained for comparison purposes and were remarkably similar to those for the 12-item ICU total score. Table 3 presents zero order correlations between CU scores, and empathy and prosocial behavior scores, and partial correlations controlling for conduct problems. Resolved ICU total and subscale scores were moderately correlated with parent-reported UNSW CU scores. Standardized betas from regression analyses controlling for the other ICU subscale revealed that the uncaring scale was most strongly associated with the UNSW CU measure (Table 3). Total ICU and subscale scores were also moderately negatively correlated with GEM total and cognitive empathy scales. The association between ICU total scores and the GEM affective scale increased to significance when covarying conduct problems. At the subscale level, affective empathy was weakly associated with uncaring, which reduced to nonsignificance after covarying callousness. ICU total and subscale scores were negatively correlated with parent- and teacher-reported prosocial behavior, and remained significant after controlling for conduct

8 JAbnormChildPsychol Table 2 Fit indices for the four models tested Model Χ 2 (df) p CFI TLI RMSEA AIC Hawes et al. (2014b) two factor model (uncaring, callous) (53) < Three factor bifactor model (e.g., Ezpeleta et al., Kimonis et al. 2008b) (184) < , Houghton et al. (2013) two factor model (uncaring, callous) (103) < Willoughby et al. (2015) two factor model (empathic/prosocial, CU) (251) < , CFI = comparative fit index; TLI = Tucker-Lewis index; RMSEA = root mean-square error or approximation; AIC = Akaike information criterion problems. Demonstrating discriminant validity, ICU subscale scores were uncorrelated with parent-reported anxiety after covarying conduct problems. Concurrent Validity: Antisocial-Aggressive Behavior As reported in Table 3, ICU total, uncaring, and callousness scores were significantly correlated with measures of antisocial and aggressive behavior. Specifically, they were positively associated with resolved scores on ECBI/SESBI conduct problem intensity, psychopathy-linked narcissism (ICU total and callousness) and impulsivity on the APSD, and teacherreported overt and relational aggression. When covarying conduct problems, associations with narcissism (for 24-item ICU) and relational aggression reduced to non-significance. Associations between ICU subscales and relational aggression also reduced to non-significance after covarying the other ICU subscale. Table 3 Associations between CU scores and main study variables ICU total (24 item) ICU total (12 item) ICU Uncaring ICU Callousness CU Scale-UNSW UNSW CU Scale 0.49*** [0.42***] 0.47*** [0.38***] 0.47*** (0.37***) 0.35*** (0.18*) GEM Cognitive 0.33*** 0.31*** 0.25** 0.30*** [ 0.20**] [ 0.18*] ( 0.10) ( 0.20**) GEM Affective.15 a * 0.11 [ 0.17*] [ 0.16*] ( 0.11) ( 0.03) GEM Total 0.32*** 0.31*** 0.27*** 0.28*** [ 0.25***] [ 0.23**] ( 0.14) ( 0.17*) SDQ Prosocial Behavior 0.44*** 0.41*** 0.36*** 0.34*** [ 0.38***] [ 0.34***] ( 0.25*) ( 0.22**) PSBS Prosocial Behavior 0.56*** 0.54*** 0.60*** 0.38*** [ 0.53***] [ 0.51***] ( 0.52***) ( 0.12) SDQ Anxiety 0.16* [0.02] [ 0.02] (0.03) (0.08) APSD Narcissism 0.40*** 0.47*** 0.32*** 0.47*** [0.10] [0.21**] (0.12) (0.38***) APSD Impulsivity/CP 0.59*** 0.63*** 0.49*** 0.60*** [0.35***] [0.43***] (0.28***) (0.47***) ECBI/SESBI T-Score 0.47*** 0.49*** 0.34*** 0.48*** (.14 a ) (0.39***) PSBS Aggression -Relational 0.18** [0.02] -Overt 0.41*** [0.24***] 0.25*** [0.12] 0.46*** [0.30***] 0.22** (0.13) 0.48*** (0.38***) 0.22** (0.13) 0.34*** (0.14*) 0.33*** [ 0.24**] 0.35*** [ 0.37***] 0.51*** [ 0.47***] 0.93*** [ 0.92***] 0.29*** [ 0.23**] 0.08 [ 0.02] 0.16* [0.21**] 0.33*** [0.16*] 0.32*** 0.05 [ 0.02] 0.22** [0.10] a p =0.05;*p <0.05;**p <0.01;***p < Brackets [] denote partial correlations controlling for resolved conduct problems; Parentheses () denote standardized betas from regression analyses with ICU subscales entered into the model together. ICU scores are resolved (combining parent and teacher report) and the 12-item total score and subscale scores are from Hawes et al. (2014b) two-factor model. UNSW CU scores are parent-reported. GEM = Griffith Empathy Measure (Parent report); SDQ = Strengths and Difficulties Questionnaire (Parent report); PSBS = Preschool Social Behavior Scale (Teacher report); APSD = Antisocial Process Screening Device Resolved; CP = Conduct problems; ECBI/SESBI = Eyberg Child Behavior Inventory/ Sutter-Eyberg Student Behavior Inventory CP Intensity Resolved score

9 J Abnorm Child Psychol Concurrent Validity: Laboratory Emotion Tasks Preliminary analyses revealed developmental differences in emotion recognition. One-way ANOVA results revealed significant differences by age (three, n = 21; four, n =51;5years, n = 124) in recognizing anger (F(2168) = 9.61, p < 0.001), fear (F(2164) = 9.86, p < 0.001), happiness (F(2164) = 26.07, p < 0.001), sadness (F(2164) = 17.79, p < 0.001), and pain (F(2164) = 3.73, p < 0.026). Post-hoc Bonferroni tests indicated that 3- and 4-year olds were significantly less accurate in identifying expressions of anger, fear, and sadness relative to 5-year olds; 4-year olds differed from 5 year olds on pain accuracy; all age groups differed on happiness accuracy. For example, only 25 % of 3-year-olds recognized fear whereas this increased to 39 % by age 4 and 51 % by age 5. Differences were most pronounced for happy expressions that were correctly identified by 60 % of children at age 3, 83 % at age 4 and 89 % at age 5. 4 Results were in a similar direction for the static and dynamic emotion recognition tasks, but effects were more robust for the dynamic task. As such, results for the dynamic task are presented in tables. There were several negative correlations between ICU scores and emotion recognition scores (Table 4). Children scoring high on resolved ICU total and uncaring subscale scores were less accurate in recognizing anger, fear, happiness, and sadness, than those scoring low. Callousness was only associated with poor fear and sadness recognition, but not after covarying uncaring scores. Uncaring scores remained significantly negatively associated with anger, happy, and sad recognition after covarying callousness. Correlations remained relatively unchanged when controlling for conduct problems and for demographic covariates (sample, age, sex). There were also developmental differences in performance on the dot probe task. On average, 3-year-olds provided the correct response on 68 % of trials, 4-year-olds on 88 % of trials, and5-year-oldson95%oftrials.asaresult,onlychildrenages 3.5 years and older and those who responded correctly to 70 % or more trials were included in analyses. CU total and subscale scores were not significantly associated with facilitation to distress scores, with rs ranging from 0.01 to Overall, high-risk children showed poorer performance on emotion tasks. Specifically, relative to mainstream children, high-risk children were significantly less accurate in recognizing all emotions (anger, happiness, sadness, fear, pain) on the static and dynamic faces tasks. On the emotional pictures dot-probe task, the average number of correct trial responses for mainstream children was 94 % whereas the average number for high-risk children was 72 %. Whereas children in the mainstream sample on average showed the expected positive facilitation to empathy pictures (M =56.12,SD = ms), the high-risk sample showed a negative facilitation similar to samples of incarcerated adolescents (M = 28.25, SD = 56.12; Kimonis et al. 2007, 2008a); however this difference was not statistically significant. Since several prior studies find reduced facilitation to distress on the dot probe task only in the presence of co-occurring conduct problems (Kimonis et al. 2006b, 2008a), groups were created on the basis of high and low resolved CU and CP symptom scores. The High CU-CP group scored greater than one standard deviation above the mean on 12-item total ICU and on ECBI/SESBI conduct problem intensity (corresponding to a T-score > 55); the CP-only group scored below this cut score on the ICU but above it on ECBI/SESBI intensity; the CU-only group scored above this cut score on the ICU but below it on ECBI/SESBI intensity; and the Low CU-CP group scored below the cut score on both measures. This method identified 10 % of the sample displaying elevated cooccurring CU traits and conduct problems. Given the small number of children categorized in the CU-only group (n = 8)it was eliminated from analyses. Results of a one-way ANOVA to compare groups on dot probe task performance indicated a significant difference on facilitation to distress, F(2143) = 3.69, p = 0.027, partial eta 2 =0.049,d =0.45.A post-hoc Bonferroni test revealed a significant difference (p = 0.038) between Low CU-CP (M = ms, SD = , 95 % CI [28.59, ]) and High CU-CP groups (M = , SD = , 95 % CI [ , 27.60]), but not CP only children (M = 11.74, SD = , 95 % CI [ 66.22, 89.69]), as depicted in Fig. 1. Discussion The purpose of the current study was to test the factor structure, psychometric properties, and validity of a brief but comprehensive parent- and teacher-report measure of CU traits among a preschool sample, and to extend the literature by validating scores against several indices of emotional functioning central to psychopathy (Cleckley 1941). This study contributes three key findings to the literature. First, confirmatory factor analyses supported the correlated two-factor structure (callous and uncaring) of the ICU identified by Hawes et al. (2014b) among older school-aged clinic-referred youth, over several alternative factor structures previously identified in the literature. Second, our findings support the utility of the parent- and teacher-report versions of the ICU for assessing CU traits in 3 to 5 year-old children. This is the first study to demonstrate that children under age 6 who score high on the 12-item and 24-item total ICU show poorer recognition of facial expressions and less attentional orienting to distress cues when they also score high on conduct problems, relative to those low on CU and conduct problems. Furthermore, preschool children rated high on the ICU by parents and teachers were more likely to be antisocial and aggressive, and to score high on other psychopathy dimensions than children scoring low. Third, these findings support the use of laboratory tasks adapted to be developmentally appropriate for assessing

10 JAbnormChildPsychol Table 4 Associations between CU scores and accuracy scores on the dynamic emotion recognition task ICU total (24 item) ICU total (12 item) ICU Uncaring ICU Callousness CU Scale-UNSW ECBI/SESBI Anger 0.18* [ 0.23**] Fear 0.28*** [ 0.31***] Happy 0.26*** a [ 0.23**] Sad 0.25*** [ 0.27***] Pain 0.12 [ 0.06] 0.15 [ 0.19*] 0.20** [ 0.22**] 0.23** b [ 0.19*] 0.25** [ 0.27***] 0.07 [ 0.01] 0.23** ( 0.24**) 0.17* ( 0.10) 0.31*** ( 0.29***) 0.29*** ( 0.25**) 0.12 ( 0.12) 0.05 (0.07) 0.18* ( 0.11) 0.12 (0.03) 0.16* ( 0.02) 0.03 (0.03) 0.21* [ 0.22**] 0.27*** [ 0.27***] 0.23** [ 0.22**] 0.20* [ 0.17*] 0.00 [0.05] *p < 0.05;**p < 0.01; ***p < Brackets [] denote partial correlations controlling for resolved conduct problems. Parentheses () denote standardized betas from regression analyses with ICU subscales entered into the model together. ICU and ECBI/SESBI scores are resolved (combining parent and teacher report) and the 12-item ICU total score and subscale scores are from Hawes et al. (2014b) two-factor model; UNSW CU scores are parentreported; ECBI/SESBI = Eyberg Child Behavior Inventory/Sutter-Eyberg Student Behavior Inventory Conduct Problem Intensity Resolved T Scores. a,b Controlling for covariates (sample, age, sex), associations reduced to non-significance: Std B = 0.07 for 24-item ICU total, Std B = 0.06 for 12-item ICU total emotional responding among young children ages 3.5 years and older. CU scores are meaningful in children as young as age 3, to the extent that they are associated with well-established correlates including deficits in emotional functioning thought to be core to psychopathy. A large number of studies have documented that, compared with typically developing youth or youth with other psychopathologies, school-aged children and adolescents with CU traits are less likely to attend to, react to, and recognize affective stimuli, particularly distress cues such as fear and sadness in others (for a review see Viding and Kimonis 2015). Our findings suggest that early recognition deficits may be more global than specific, which is consistent with findings from a recent meta-analysis of emotional deficits in psychopathy (Dawel et al. 2012; cf. Marsh and Blair 2008). Consistent with prior studies of older youth, CU traits were Fig. 1 Mean facilitation to distress (milliseconds) scores on the emotional pictures dot-probe task for low conduct problem (CP)/low callousunemotional (CU) (n = 94), high CP only (n = 41), and High CP/CU (n = 11) groups only associated with deficient attentional orienting to distress cues when conduct problems were also present (Kimonis et al. 2006b, 2008b). 5 The combination of CU traits and conduct problems generally appears to identify youth who show similar correlates to adult psychopathy, including sensation seeking, fearlessness, deficient emotional processing, and severe, chronic, and proactive antisocial and violent behavior (see Frick et al. 2014). This study is the first to test the factor structure of the ICU among young children by comparing several alternative models using both parent and teacher-reported scores. Similar to research on the parent-reported ICU with schoolaged children (Hawes et al. 2014b) it finds that a two-factor model that eliminates all but one unemotional item, indicated by only 12 of the original 24 items, provided optimal fit. This is contrary to the majority of factor analytic studies with older children and adolescents using self-report scores that support a three-factor bifactor structure. ICU total and subscale scores were internally consistent, with coefficients similar in range to those reported in prior studies conducted with school-aged children, adolescents, and young adults. Also, the ICU scale was moderately correlated with another measure of CU traits, namely the UNSW CU measure used by Dadds et al. (2005, 2006, 2009), and with measures of empathy and prosocial behavior. Correlations with criterion measures were highly similar between the 24-item and 12-item ICU total scores, suggesting that the additional items add little variance to identifying young children at risk for antisocial behavior when using parent and teacher ratings. Several of these items comprised the original unemotional factor that has consistently 5 In order to be brief enough for young children, our version of the dot probe task did not include other emotional categories, and thus cannot speak to whether young children show more pervasive and generalized attentional orienting deficits than older youth.