Is Callous Always Cold? A Critical Review of The Literature On Emotion and The Development of Callous-Unemotional Traits in Children

Clinical Child and Family Psychology Review
https://doi.org/10.1007/s10567-019-00309-w
Is Callous Always Cold? A Critical Review of the Literature on Emotion

and the Development of Callous–Unemotional Traits in Children
Jaimie C. Northam1 · Mark R. Dadds1
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Low emotional responsiveness is considered a core feature of callous–unemotional (CU) traits in childhood and, in the context
of antisocial behavior, a precursor of psychopathic traits in adulthood. However, recent findings suggest that CU traits are not
always characterized by low emotional responsiveness and the evidence base requires review. This review asks a fundamen-
tal question— ‘Is callous always cold?’—with a specific focus on emotional responsiveness and CU traits in children with
conduct problems (CPs). PRISMA review protocols were followed to identify literature reporting on emotional responsive-
ness for children 3–18 years with CPs and varying (high and low) CU traits. Results from eligible studies were contrasted
by age (children 3–11 years, adolescents 12–18 years), emotional responsive measurement type (physiological, behavioral,
self-report), emotion-eliciting stimuli type (interactive activities, static imagery, film) and socio-emotional context of the
stimuli (other-orientated, self-orientated, neutral). This review highlights considerable variation in results across studies:
reduced emotional responsiveness was not synonymous with participants demonstrating high CU traits. A more consistent
picture of reduced emotional responsiveness in participants with high CU traits was found when studies used physiological
measures, when stimuli were other-orientated in socio-emotional context, and in older, adolescent samples. In conclusion,
this paper advocates for a more nuanced understanding of the relationship between high CU traits and the specific factors
involved in emotional responsiveness, ultimately suggesting that callous is not always cold. Given that emotional responsive-
ness is central to theories of moral development, these findings may suggest innovative approaches to early intervention.
Keywords Callous–unemotional traits · Emotional responsiveness · Childhood psychopathology · Conduct problems ·

Psychopathy
Since the conception of the human sciences, philosophers known as callous–unemotional (CU) traits and are thought
and psychologists have attempted to understand what drives to be a hallmark of psychopathy—present since birth and
people to act antisocially. These attempts have yielded often genetically-influenced (e.g. Blair et al. 2006; Frick
descriptive personality profiles, incorporating taxonomies and Viding 2009; Viding and McCrory 2012). Accordingly,
of antisocial behaviors and interpersonal characteristics. One models attempting to forecast adult psychopathic traits pro-
highly influential approach to this was Cleckley’s (1941) pose dampened emotional responsiveness to be a persistent
seminal work into psychopathy. Those with psychopathic temperamental factor, theoretically observable in samples
traits are known for their behavioral profiles, demonstrating of children (as per Blair 2005; Herpers et al. 2014; Patrick
both severe antisocial behaviors and affective deficits, such 1994).
as a shallow affect, lack of empathy and remorse, and low Surprisingly, to date, no exhaustive review of the empiri-
emotional responsiveness to others’ emotional cues (Frick cal literature on dampened emotional responsiveness and
and Marsee 2006; Hare 2003). These affective deficits are CU traits in children and adolescents with conduct problems
(CPs) exists. This review asks for the first time: what is the
evidence that callousness is always associated with reduced
* Jaimie C. Northam
jaimie.northam@sydney.edu.au emotional responsiveness? Or, is callous always cold? In
what follows, we provide a brief background on CU traits
1
Child Behaviour Research Clinic, School of Psychology, The in children before examining historical and contemporary
University of Sydney, 97 Church Street, Camperdown, NSW,
Australia
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Vol.:(0123456789)
methods for defining, eliciting and measuring emotional 2009). Accordingly, research on heterogeneity within con-
responsiveness as a context to the review. duct-disordered children has often focused on the differences
between those with high and low CU traits.
An emphasis has been placed on differentiating children
Definitions of Key Terms and Constructs with high and low CU traits based on their emotional respon-
siveness and potential errors in emotional processing (e.g.
Emotion-based literature is complex, relying on multiple Ciucci et al. 2015; Fanti et al. 2017; Kimonis et al. 2017;
constructs to describe related phenomena. However, with Viding et al. 2012), which are suggested to occur on multiple
multiple constructs come multiple, sometimes contradictory, components required for effective emotion processing (e.g.
terminology. Prior to reviewing extant literature, it is impor- Woodworth and Waschbusch 2008). Specifically, children
tant to operationalize the terms and constructs that will be with CPs and high CU traits have been found to attend (Blair
used throughout this review. Henceforth, ‘emotional respon- et al. 1999), recognize (Dadds et al. 2006; Leist and Dadds
siveness’, ‘emotionality’ and ‘emotional reactivity’ will be 2009) and react (Blair et al. 1999, 2001; Kimonis et al. 2017;
used interchangeably when referring to a multi-systemic Loney et al. 2003) to emotional stimuli differently to chil-
emotion-related response to an eliciting stimulus (Leven- dren with CPs and low CU traits. These differences have
son 2007). Emotional responsiveness is operationalized as been proposed to result in cascading errors in components
a responsive change from baseline homeostasis, reflected in essential for accurate emotional processing (e.g. Shariff and
physiological, neurological and behavioral systems (Leven- Tracy 2011).
son 2014; Mauss and Robinson 2009). Likewise, the term Several well known and frequently cited studies have
‘emotion processing’ will refer to the higher order, ‘top- shown that children with high CU traits show reduced emo-
down’ processes which rely on the multi-systemic responses tional responsiveness when compared to children with low
to an eliciting stimulus in order to interpret, make assump- CU traits (e.g. Anastassiou-Hadjicharalambous and Warden
tions and appraisals of the evocative stimuli (Dalgleish 2008; Blair et al. 1999; Kimonis et al. 2017; Viding et al.
2004). 2012). Nonetheless, such findings are inconsistent across
the literature. One explanation for this inconsistency may
be methodological in nature, as the range of emotion elicita-
The Construct of Psychopathy and CU Traits tion methods and emotional reactivity measures used vary
in Children between studies. Recent review papers (e.g. Fanti 2018;
Moul et al. 2018) have attempted to address this problem
Affective deficits, including reduced emotional responsive- by further specifying deficits in emotional responsiveness
ness, have been well documented in psychopathy literature with consideration of heterogeneity in CPs based on specific
(Blonigen et al. 2006; Cleckley 1982; Herpertz et al. 2001; emotion processing systems. For example, Moul et al. (2018)
Patrick et al. 1993). People demonstrating antisocial behav- provides a synthesis of the literature outlining a biobehavio-
iors and high psychopathic traits have shown dampened ral account of antisocial behaviour and CU traits, providing
responsiveness to threat cues (e.g. Lykken 1957), reduced support for neurological measurement methods of emotional
emotion-modulated startle response (e.g. Patrick et al. 1993), reactivity (e.g. fMRI measures). In this account, a neuro-
reduced autonomic arousal to distress cues (e.g. Blair et al. cognitive model with an emphasis on hypoactivity in the
1997) and reduced emotion-mediated attention and memory amygdala to emotional cues of others is proposed as key.
to emotional cues when compared to people demonstrat- Impaired amygdala function is described to effect empathic
ing antisocial behaviors and low psychopathic traits (e.g. processes and associative learning, specifically about asso-
Kiehl et al. 1999). These affective deficits are thought to ciations between a person’s own behaviors and consequen-
reliably predict psychopathy and indicate a specific tempera- tial affective responses of others. Impairments (i.e. reduced
ment associated with fearlessness (Birbaumer et al. 2005; reactivity) in neurocognitive processes are one example of
Hare and Neumann 2009; Lorenz and Newman 2002; van physiological methods used measure emotional reactivity.
Honk and Schutter 2007). Although psychopathy is a con- Another system of physiological measurement of emo-
struct only applied to adults, the emotional components of tional reactivity used in studies is that of autonomic nervous
the personality profile (i.e. CU traits) can be reliably identi- system (ANS) arousal. Fanti (2018) provides a review of
fied in children and adolescents, with such traits elevated the role emotional responsiveness on psychophysiological
in samples of those with CPs (Frick and Viding 2009). systems (e.g. skin conductance, electromyography, heart-
Research has demonstrated that developmental outcomes rate and eye-blink startle response) in participants with CU
vary for children with CPs, with explanations for this vari- traits. This review highlights the importance of this type of
ance often attributed to CU trait status (e.g. Blair et al. 2006; measurement strategy and the potential role that ANS hypo-
Fontaine et al. 2011; Frick et al. 2003; Frick and Viding activation plays on empathy and emotional responsiveness.
13
However, this review also highlights clear discrepancies emotional deficits in the case of those with CU traits—across
in ANS responses based on CU trait subtype. Participants multiple sites involved in the experience and elicitation of
scored on opposite ends of responsiveness based on CU emotion. This is particularly so for children and the potential
subtypes—those with primary variants of CU traits show- influence of CU traits on emotional development.
ing lower emotional reactivity while those with secondary As this review is interested in emotional responsiveness,
variants demonstrated more. as opposed to the more complex process of emotion process-
Both of these recent and targeted reviews (i.e. Moul et al. ing, emotion responsiveness has been categorized into four
2018; Fanti 2018) indicate impairments in physiological measurable domains: (1) central nervous system responses,
components of emotional responsiveness in those with high such as functional neuroimaging methods; (2) autonomic
CU traits. These papers provide an important synthesis of the nervous system responses, such as peripheral physiological
evidence of emotional responsiveness in children with CU measurement; (3) behavioral responses, such as displayed
traits; however, they are limited to very specific emotional emotion and reaction times; and (4) subjective responses
responsiveness measurement methods. This means that the (e.g. Kreibig 2010; Levenson 2007). As described by Mauss
generalizability of these findings is limited to these specific et al. (2005), there is important information to be gained
physiological systems and as yet, there are no reviews that from each of these domains and, when taken together, each
consider the influence of varying emotional reactivity meas- contributes to a more comprehensive and integrated under-
urement strategies. Further synthesis of extant literature is standing of emotional responding.
needed to test whether, under all measurement conditions In order to generate an emotional response, an evocative
and contexts, callous is always cold. In order to do this, a stimulus is needed. Levenson (2007, 2014) suggests that,
brief foray into the emotion theory literature is needed to under experimental conditions, emotion-eliciting stimuli
establish terms and provide rationale for the focus of this typically fall into three categories: (1) participation in inter-
review. active activities (e.g. a disappointment task, as outlined
in Cole et al. 1994); (2) exposure to imagery (e.g. Inter-
national Affective Pictures System, see Lang et al. 1997);
Components and Contexts of Emotion and (3) exposure to film (e.g. 6-min emotional scene from
The Lion King [1994], as used in Dadds et al. 2016). Stud-
To help disentangle the role of emotional responsiveness in ies exploring emotional responsiveness tend to use a single
CU traits, some initial commentary on the definitions, func- emotion-eliciting stimuli type. While practical, given the
tion and controversies in the measurement of ‘emotion’ is many constraints of experimental lab-based experiments,
needed. There is general consensus that an emotion is a psy- methodologies incorporating singular emotion-eliciting
chological state that occurs as a multilayered process (Hock- stimuli types may lead to generalizations about the results—
enbury and Hockenbury 2010). These layers are typically i.e. findings related to emotional responsiveness from a spe-
considered to include a subjective component (feelings), a cific stimulus may be represented as more characteristic then
cognitive component (appraisals), a physiological compo- they actually are. The same holds in the study of emotional
nent (central and peripheral nervous system), a behavioral responsiveness. The type of stimuli used to elicit an emotion
component (action tendencies) and an expressive component (e.g. tasks, imagery, film) and the socio-emotional context
(Schröder et al. 2007). The extent to which each of these of those stimuli are likely to influence emotional responsive-
components interacts with each other, or is precipitated or ness. Thus, careful consideration is needed in constructing
activated in a sequence, is a much more contentious issue methodologies.
(for review, see Dalgleish 2004) and outside the scope of In regards to the socio-emotional context of stimuli,
this review. returning to the theoretical underpinnings of emotions is
When discussing emotion literature, an apt metaphor is a useful exercise. Emotions hold a central place in the his-
that of the blind men attempting to define an elephant. Each tory of theories of human behavior. They motivate adaptive
man defines ‘an elephant’ based on what they can ‘see’ with behavior and, through their expression, convey important
their hands and, as such, do not have a complete picture social information (Abe and Izard 1999). As originally
of its shape, size or nature. Emotion theory and literature suggested by Darwin (1872) in his work ‘The expression
as it pertains to CU traits is in a similar predicament. The of the emotions in man and animals’, human emotion can
science related to emotion measurement has progressed be considered to serve two specific functions: (1) prepara-
exponentially over the previous 15 years, with increased tion for adaptive responding to environmental threat; and
use of powerful physiological measures leading to greater (2) the communication of social information (Shariff and
scientific rigor and more sophisticated accounts of emotional Tracy 2011). This concept, as it relates to research on emo-
processes (e.g. Lewis et al. 2010; Swan 2013). However, lit- tional responsiveness in individuals with high CU traits,
tle evidence exists for an integrated account of emotion—or is an important one. The purpose of emotions may be
13
‘self-oriented’ (i.e. emotions that activate behaviors for self- The first aim was to explore whether reduced emotional
preservation and meeting one’s own needs) or ‘other-orien- responsiveness is more consistently demonstrated in chil-
tated’ (i.e. emotions that activate behaviors to meet the needs dren with CPs and high CU traits compared to those with
of others). Both types of emotional responsiveness trigger CPs and low CU traits. It was expected that, like their adult
approach-avoidance behaviors motivated by self-welfare or counterparts, children with CPs and high CU traits would be
preservation in the former, or approach-avoidance behaviors more likely to demonstrate reduced emotional responsive-
motivated by other-welfare in the latter (e.g. Elliot 2006). ness when results were compared to those with CPs and low
Both types of emotional responsiveness (self-orientated CU traits.
and other-orientated) play an undisputable role in healthy The second aim was to explore whether methodological
human functioning and emotional development. How CU variations across studies yielded differences in emotional
traits influence emotional responsiveness under these dif- responsiveness results. Based on previous work demon-
ferent socio-emotional context is unknown. strating that adults with psychopathic traits have reduced
Foundational to conceptualizations of CU traits is the emotional responsiveness compared to other groups when
‘unemotional’ component that outlines an apparent disre- measured physiologically (e.g. Levenston et al. 2000; Verona
gard to the rights and welfare of others, in addition to empa- et al. 2004) and that responses demonstrating reduced emo-
thy deficits and a lack of remorse (Frick and Marsee 2006). tionality are less predictable when measured behaviorally
Accordingly, it is possible that those with high CU traits and by subjective experience (e.g. Ellis et al. 2017), a simi-
may demonstrate typical emotional responsiveness to stimuli lar pattern of responding was expected when results were
that have a self-orientated socio-emotional context and lower considered in studies examining children with CPs and high
emotional responsiveness to stimuli that are other-orientated. compared to low CU traits. Specifically, when results of
Consideration of past literature of emotional responsiveness studies were compared on the basis of emotional measure-
in those with CU traits with this level of socio-emotional ment type (fMRI, peripheral physiological, overt behavior,
distinction in the stimuli may provide a more nuanced under- subjective experience), it was predicted that physiological
standing of emotional deficits in these individuals. measures of emotional responsiveness would be more robust
Another complicating factor in the measurement of than others in demonstrating reduced responsiveness for
emotional responsiveness is the influence of age and devel- high CU trait groups. When emotion-eliciting stimuli types
opmental stage. How humans respond, experience and (i.e. interactive activities, imagery, film) were compared, it
express emotion changes significantly throughout their was predicted that no single stimulus type would be more
lives (Labouvie-Vief et al. 2007). Healthy childhood devel- robust in demonstrating reduced emotional responsiveness
opment involves the acquisition of skills for theory of mind, for those with high CU traits.
emotion regulation and the ability to comprehend and label Given the differing socio-emotional context of emotion-
emotional experiences (Wellman and Liu 2004; Peterson eliciting stimuli (i.e. self-orientation vs. other-orientation)
et al. 2012). This learning typically results from children’s and the potential for these to affect emotional responsive-
interactions with their parents and more general observa- ness in adults with psychopathic traits (i.e. Blair et al. 1997;
tions of the environment, which help to inform a model of Morrison and Gilbert 2001), the third aim was to explore
socially-appropriate emotional expression (Eisenberg 2000). the influence of the socio-emotional context of the emotion
Changes in emotional experience and expression between eliciting stimuli on emotional responsiveness results. Spe-
earlier childhood and puberty may be particularly evident cifically, our aim was to explore whether emotional respon-
(e.g. Pollak and Fries 2001). Thus, we argue that the study siveness differed in response to: a stimulus that affected the
of emotional experience should not only consider the type participant directly (i.e. inducing self-orientated emotions,
of emotional stimuli used to elicit an emotional response and such as a frustration induction task); a stimulus that affects
how it is measured, but the age of the participants as well. someone else (i.e. inducing other-orientated emotions, such
as watching a film in which the protagonist experiences dis-
tress); or a stimulus with little or neutral social context (such
The Current Study Aims as exposure to a static image of an emotional expression).
Based on the notion that reduced emotional responsiveness
To help clarify etiological conceptualizations of childhood affects social learning processes related to ‘other-orientated’
CPs, this paper aims to provide a systematic review of the stimuli, such as empathy and development of prosocial atti-
literature assessing for evidence that the dampened emo- tudes and behaviors, it was predicted that reduced emo-
tional responsiveness associated with adult psychopathic tional responsiveness would be demonstrated more often in
traits is also present in samples of children and adolescents children and adolescents with high CU traits in response to
with CPs and high CU traits. In order to do so, this study ‘other-orientated’ stimuli than ‘self-orientated’ or ‘neutral’
had three specific aims. stimuli.
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Method Search Terms
This method used a systematic approach as described in Pet- Keyword searches of the following electronic databases were
ticrew and Roberts (2008) to identify studies reporting on undertaken on MEDLINE, PsychINFO and Embase. There
emotional responsiveness in children and adolescents with CPs were three groups of search terms used to identify studies.
and varying levels CU traits. The selection process was under- Terms were set broadly, with the aim of initially identifying
taken in accordance with PRISMA guidelines (see Moher et al. as many relevant studies as possible. The first group related
2009). to emotional responsiveness and included the terms ‘emo-
tion’, ‘affect’, ‘emotional reactivity’, ‘emotion processing’,
Inclusion/Exclusion Criteria ‘emotional response’ and ‘emotion elicitation’. The second
group related to CU traits and included ‘callous unemotional
The primary inclusion criterion was age, including children traits’, ‘limited prosocial emotions’, ‘fearlessness’, ‘psycho-
and adolescents aged 18 years and below who met criteria for pathic’, ‘psychopathy’, ‘meanness’ and ‘proactive aggres-
clinically-significant CPs and were judged to have either high sion’. The third group related to emotional measurement and
or low CU traits by use of an empirically-validated measure. included the terms ‘facial expression’, ‘heart rate’, ‘pupil
As this paper aimed to assess the influence of children with dilation’, ‘gaze aversion’, ‘attention’, ‘respiration’, ‘gal-
CPs and either high or low CU traits, studies on CU traits vanic skin response’, ‘self report’, ‘behavior observation’,
in samples with no reported or evident CPs were excluded. ‘behavior’, ‘behavior’, ‘autonomic nervous system’, ‘electro-
Likewise, studies that measured psychopathic traits without dermal activity’, ‘electromyography’, ‘startle’, ‘eye blink’,
specific measures of CU traits were excluded. Although the ‘emotional language’, ‘fMRI’, ‘ERP’ and ‘event-related
affective dimension of psychopathy is often represented by potential’. Due to the large number of studies initially iden-
the inclusion of CU trait subscales, contributing to total psy- tified, a fourth search group of child and adolescent terms
chopathy scores in measures such as the Youth Psychopathy was identified and used with the ‘AND’ function, meaning
Inventory (Andershed et al. 2002), it is possible for high total that the above search terms were valid if they included one
psychopathy scores to be reached based on the presence of of the child/adolescent terms. These included ‘childhood’,
antisocial behavior alone. For the purpose of this review, ‘children’, ‘early onset’, ‘adolescent’, ‘adolescence’, ‘youth’,
any article that provided only total scores for psychopathic ‘young person’ and ‘teenager’.
traits and not a CU trait subscale, was deemed ineligible for
inclusion. Study Selection and Data Extraction
Studies required the inclusion of discrete experimental
emotion-eliciting stimuli and the measurement methods of Figure 1 describes the study selection process follow-
emotional responsiveness. There were no restrictions on pub- ing PRISMA protocol, starting with an initial 849 stud-
lication date. However, as the CU construct is a recent addition ies identified, which, after duplicates were removed, titles
to the research literature, the oldest article found eligible for screened and abstracts reviewed, left 69 articles for full-text
inclusion was published in 2003. review. A secondary coder reviewed a random sample of
50 titles (15%) and 89 abstracts (50%) based on inclusion
Information Sources and exclusion criteria, with an agreement of 100% with the
primary coder at both title and abstract levels. As many of
The following sources were searched: the abstracts did not include information about whether CU
traits were included as an independent measure and did not
(1) Electronic bibliographic databases (20–30/08/2017, provide specific information about the nature of the meth-
02/08/2019): MEDLINE, PsychINFO, Embase, Pro- odologies employed, a full-text review was deemed neces-
quest International Dissertations and E-theses. sary for a total of 69 articles. Both primary and second-
(2) Search Engines (02/09/2017, 02/08/2019): Google, ary coders reviewed the 69 articles independently, with 21
Google Scholar. meeting inclusion criteria. Agreement about study inclusion
(3) Reference list searching: the reference lists of all papers was 100% and agreement about exclusion reasons was 98%.
considered suitable for inclusion were hand searched to Figure 1 shows a flow chart of article selection, including
identify further suitable studies. reasons for exclusion at the full-text level.
From the 21 studies deem eligible information was
abstracted on study sample size, recruitment, age, CU trait
measurement method, type of emotion-eliciting stimulus,
method used to measure emotion and difference testing
results between high and low CU trait groups. Tables 1, 2, 3
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Fig. 1 The selection process following PRISMA protocol (Moher et al. 2009)
Table 1 Demographic information of child studies (9)

Study Sample size Sample type % Female Age range (M) Conduct problem CU traits measure
measure
Anastassiou-Had- 95 Clinical 4 7–11 Revised Rutter Teacher APSD–CU subscale

jicharalambous and Scales for School-age
Warden (2008) Children
Dadds et al. (2016) 76 Clinical 26 4–14 (7.1) DISCAP UNSW System
Ezpeleta et al. (2017) 320 Clinical 48 8 SDQ ICU
Fanti et al. (2016) 73 Clinical 45 (11.2) Child Symptom Inven- ICU
tory for Parents-4
Helseth et al. (2015) 60 Clinical 30 6–12 (9.04) DBDRS and DISC-IV APSD–CU subscale
Ragbeer (2015) 73 Clinical 100 9–13 (10.7) APSD APSD–CU subscale
Sharp et al. (2006) 659 Community 52 7–11 SDQ APSD–CU subscale
Souroulla et al. (2019) 87 Community 48 10.1–12.8 (11.2) CBCL ICU
Yoder et al. (2016) 106 Clinical and community 49 9–11 (10.55) DISC Predictive Scale ICU
for CD
Age range and means are both reported when possible

ICU Inventory of Callous–Unemotional Traits, APSD Antisocial Process Screening Device, CD Conduct Disorder, CBCL Child Behaviour
Check List, SDQ Strengths and Difficulties Questionnaire, DBDRS Disruptive Behaviour Disorder Rating Scale, DISC-IV Diagnostic Interview
Schedule for Children, DISCAP Diagnostics Interview Schedule for Children, Adolescents and Parents
13
Table 2 Demographic information of adolescent studies (12)

Study Sample size Sample type % Female Age (M) CPs measure CU traits measure
Cardinale et al. (2018) 48 Clinical 31 10–17 (14) SDQ and CBCL ICU
De Wied et al. (2012) 44 High risk/clinical 0 12–15 (13.63) CBCL APSD–CU subscale
Hwang et al. (2016) 67 Community 38 (14.35) K-SADS ICU
Kimonis et al. (2017) 238 Forensic 0 (16.8) DSM-IV criteria ICU
Lozier et al. (2014) 46 Community 43 10–17 SDQ and CBCL ICU
Loney et al. (2003) 65 Forensic 0 12–18 (16.01) CASI-4R APSD–CU subscale
Martin-Key et al. (2017) 77 Forensic and school 0 13–18 K-SADS ICU
Masi et al. (2014) 62 Clinical 18 8–16 (11.3) CBCL ICU
Sakai et al. (2016) 72 Clinical 0 15–18 (16.7) DISC-IV ICU
Schwenck et al. (2012) 92 Clinical 0 6–17 (12.3) DSM-IV TR ICU
Schwenck et al. (2017) 43 Clinical 0 11–17 (14.34) Kinder-DIPS ICU
Sebastian et al. (2014) 55 Community 0 10–16 (14) CASI-4R ICU
Age range and means are both reported when possible

ICU Inventory of Callous–Unemotional Traits, APSD Antisocial Process Screening Device, CASI-4R Child and Adolescent Symptom Inventory-
4R (Lavigne et al. 2009), K-SADS Kiddie Schedule for Affective Disorders, DISC-IV Diagnostic Interview Schedule for Children
and 4 summarize the abstracted information from the 21 arti- included established measures of CU traits (e.g. Dadds et al.
cles. Only the outcomes relevant to this review are reported 2005; Frick and Hare 2001; Kimonis et al. 2008).
in the tables. Due to the small number of papers identified The first aim of this review was to explore whether the
and significant variation in emotion reactivity measurement emotional responsiveness observed in samples of adults with
type, a meta-analysis was not deemed appropriate and the high psychopathic traits was also observable in samples of
decision to conduct a theoretical qualitative narrative was children and adolescents with CPs and high CU traits. Of
made. the 21 studies meeting eligibility criteria, 13 (62%) showed
Eligible studies were separated into groups by mean age, that either children or adolescents with high CU traits dem-
with the ‘child’ group consisting of studies with a mean age onstrated reduced emotional responsiveness on at least one
under 12 years (9 studies), and the ‘adolescent’ group with measure compared to those with low CU traits. One study
a mean age between 12 and 18 years of age (12 studies). (Dadds et al. 2016) found the opposite effect, with the high
Studies were systematically categorized based on: (1) meth- CU group demonstrating greater emotional responsiveness
odology in relation to category of emotion-eliciting stimuli compared to the low CU group. Children with high CU traits
(interactive activities, imagery, film) and emotional meas- demonstrated reduced emotional responsiveness in compari-
urement method (subjective experience, observed behavior, son to those with low CU traits in three out of 9 studies
peripheral psychophysiological arousal, fMRI); and (2) (33%), while adolescents showed this effect for 10 out of 12
socio-emotional context of the emotion-eliciting stimuli studies (83%).
(neutral, e.g. static images displaying a single facial affect
with no other contextual information; ‘self-orientated’, e.g. The Effect of Methodological Differences
frustration induced by losing a game; ‘other-orientated’, e.g. on Emotionality
watching a film of someone else in distress).
The second aim of the review was to explore whether meth-
odological differences between studies influenced emotional
Results responsiveness in CU trait groups. First, the effect of differ-
ent types of emotion eliciting stimuli were considered. As
Participant and Study Characteristics demonstrated in Tables 3 and 4, studies using imagery as
the emotion-eliciting stimulus most frequently demonstrated
As shown in Table 1, the 21 studies yielded a total of reduced reactivity for high compared to low CU trait groups
2458 participants, of which 1549 were children (9 studies) (6 out of 8 studies, 75%), followed by task-based stimuli (5
and 909 were adolescents (12 studies). Participants were out of 8 studies, 62%) and film (2 out of 5 studies, 40%). No
predominantly male, which was consistent with previ- effect was evident for emotion-eliciting stimuli type when
ous research published on children with CPs. All studies results were considered by age.
13
Table 3 Results of child studies organized by stimuli type (9)

Stimuli type (N) ER measurement Study Study results specific to CU group difference Type of stimuli
Task (3) Behavior (2) Ezpeleta et al. (2017)No difference was found between HCU and LCU Neutral
groups in reaction times for identifying different
emotions (happy, fear or neutral) in a go, no-go task
Ragbeer (2015) No differences between HCU and LCU groups in Self
observed behaviors (emotional expressions and
intensity of negative valence emotions) during a
disappointment task
Subjective experience (2) Ragbeer (2015) No differences between groups of girls with varying Self
levels of CU traits in self-reports of their affect after a
disappointment task
Helseth et al. (2015) No difference was found between HCU and LCU Self
groups in self-reports of valence on a 5-point Likert
scale, which responses ranged from 0 (very happy) to
4 (very angry), which were anchored by drawing of
happy, neutral and angry faces
Images (4) Subjective experience (3) Sharp et al. (2006) No significant differences were found between HCU Neutral
and LCU groups in self-reports of arousal and
valence for pleasant, neutral and aversive images
Yoder et al. (2016) A significant difference was found between HCU and Other
LCU trait groups—HCU trait groups less likely to
report feeling distressed than others
Souroulla et al. (2019) No significant differences were found on self-report Neutral
measures of valence and arousal, between HCU and
LCU groups in response to images depicting joy, fear,
sadness or neutrality
Images (4) Peripheral physiological (2) Fanti et al. (2016) A significant difference was found between HCU and Self
LCU trait groups in fear potentiated startle—HCU
showed diminished startle potentiation when com-
pared to LCU
Souroulla et al. (2019) No significant differences were found on measures of Neutral
heart-rate, skin conductance and EMG measures,
between HCU and LCU groups in response to images
depicting joy, fear, sadness or neutrality
fMRI (1) Yoder et al. (2016) HCU children showed less functional connectivity Other
seeded in the anterior cingulate with left amygdala
and anterior insula in response to viewing images of
other people being harmed, when compared to LCU
children
Film (2) Behavior (1) Dadds et al. (2016) Children with HCU traits expressed similar emo- Other
tional responses and emotion regulation strategies
(observed behaviours) to LCU children
Subjective experience (1) Anastassiou-Had- No significant difference found for children with HCU Other
jicharalambous and and LCU traits in self-reports of vicarious response
Warden (2008) to film
Peripheral physiological (1) Anastassiou-Had- Those with HCU traits demonstrated significantly Other
jicharalambous and lower baseline heart-rate and magnitude of HR
Warden (2008) change from baseline, than those with LCU
Next, the effect of emotional measurement methods reduced responsiveness in groups with high CU traits (6
was explored. As shown in Tables 3 and 4, physiologi- out of 6 studies, 100%), closely followed by studies using
cal measures of responsiveness were more likely to dem- peripheral physiological measures (4 out of 5 studies,
onstrate reduced emotionality in groups with high CU 80%). Subjective experience (4 out of 10 studies, 40%)
traits than observational and self-report measures. Stud- and behavioral measures (1 out of 6 studies, 17%) were
ies using fMRI-based emotional responsiveness measure- less predictable. There was little difference between age
ment showed the highest predictability of demonstrating groups on these measures.
13
Table 4 Results of adolescent studies organized by stimuli type (11)

Task (5) Behavior (2) Loney et al. (2003) A significant difference was found between HCU and Neutral
LCU in reaction times to an affective Stroop task.
HCU group demonstrated slower reaction times to
negative valenced words
Hwang et al. (2016) A significant difference was found between HCU Neutral
and LCU groups for accuracy in affect mediated
cognitive task—those with HCU traits provided
more accurate responses compared to those with
LCU traits, suggestive of reduced emotionality
in response to positive and negatively valenced
images
Subjective experience (1) Sakai et al. (2016) A significant difference was found between HCU and Other
LCU trait groups—HCU adolescents self-reported
reduced ER after observing another person conduct
a prosocial action
fMRI (3) Hwang et al. (2016) A significant difference was found between HCU Neutral
and LCU groups in response to an affective Stroop
task—HCU demonstrated decreased activation of
ventromedial prefrontal cortex (vmPFC) and amyg-
dala for negative valenced stimuli
Schwenck et al. (2017) Decreased amygdala and TPJ activation were found Self
to be significantly correlated with HCU traits
Cardinale et al. (2018) HCU adolescents exhibited left amygdala hypo- Other
activation relative to healthy controls and LCU
adolescents during evaluations of causing others
fear. CU traits moderated the relationship between
externalizing behavior and both amygdala activity
and patterns of functional connectivity
Images (4) Subjective experience (1) Masi et al. (2014) A significant difference between groups was found Neutral
in self-report measure of valence—HCU predicted
a pleasant judgment to negative images. No group
differences were found for self-reported arousal to
the images and for positive valenced images
Peripheral physiological (1) Kimonis et al. (2017) A significant difference was found between adoles- Self
cents with HCU and LCU, in which HCU group
demonstrated a reduced startle potentiation to
aversive images. No difference was found between
groups in response to pleasant images
fMRI (2) Lozier et al. (2014) No differences were found between HCU and LCU in Neutral
right amygdala responses to fear expressions. How-
ever, multiple regression analysis found amygdala
responses to fearful expression to be negatively
associated with CU traits and positively associated
with externalizing behavior when both variables
were modeled simultaneously. Reduced amygdala
responses mediated the relationship between CU
traits and proactive aggression
Sebastian et al. (2014) No difference was found between HCU and LCU Neutral
group in bilateral amygdala response when exposed
to fearful and calm faces. HCU group demonstrated
a significantly reduced response compared to LCU
group in the middle temporal gyrus (MTG)
Film (3) Behavior (1) De Wied et al. (2012) No differences in verbal or facial reactions to sadness
in a film between HCU and LCU groups
Subjective experience (3) De Wied et al. (2012) No significant difference between HCU and LCU Other
groups for self-reports of emotional experience
13
Table 4 (continued)
Film (3) Subjective experience (3) Martin-Key et al. (2017) No difference between HCU and LCU groups in Other
self-reports of emotional experience in response to
watching an actor talk about emotional memories
(happy, surprised, sad, angry, disgusted, fearful)
Schwenck et al. (2012) No difference between HCU and LCU groups in self- Other
reports of how emotionally affected they were on a
10 point Likert scale in response to watching video
scenes in which a character experienced varying
events
Peripheral physiological (1) De Wied et al. (2012) A significant difference was found between HCU and Other
LCU groups at the autonomic level (HCU showed
less HR change from baseline) in response to a sad
scene shown on film
Studies Using Multi‑systemic Measures of Emotional and 4, 8 of the 21 studies used ‘neutral’ socially-orientated
Responsiveness stimuli, 8 used ‘other-orientated’ emotional stimuli, and 5
used ‘self-orientated’ stimuli.
The results of studies that adopted multiple measures of
emotional responsiveness were also considered. Four stud- Neutral Social Stimuli
ies with child samples used multiple measures (Anastas-
siou-Hadjicharalambous and Warden 2008; Ragbeer 2015; Of the 8 studies using ‘neutral’ socially orientated stimuli,
Souroulla et al. 2019; Yoder et al. 2016). Of these, all dem- 4 (50%) demonstrated dampened emotional responsiveness
onstrated consistency within their studies: that is, multiple for high compared to low CU trait groups. Three studies
measures of responsiveness demonstrated the same effect. (Ezpeleta et al. 2017; Sharp et al. 2006; Souroulla et al.
However, the direction of the effect was not consistent. 2019) included child samples, with each finding that high
Two studies (Anastassiou-Hadjicharalambous and Warden and low CU trait groups had similar levels of responsive-
2008; Yoder et al. 2016) showed reduced responsiveness for ness. The opposite effect was seen in the five studies with
the high compared to low CU trait group in both measures adolescent samples. Four (Loney et al. 2003; Hwang et al.
[physiological measures (fMRI and peripheral physiologi- 2016; Masi et al. 2014; Lozier et al. 2014) showed reduced
cal) and subjective experience], while two studies (Ragbeer responsiveness for those with high CU traits, while one with
2015; Souroulla et al. 2019) found the high CU trait groups an fMRI-based measurement (Sebastian et al. 2014) found
to be as emotionally reactive as the low CU trait groups no difference for the primary region of interest—the bilat-
(peripheral physiological, behavior and subjective experi- eral amygdala—but a significant group effect for the middle
ence measures). temporal gyrus.
Only two studies with adolescent samples used multiple
measurements (Hwang et al. 2016; De Wied et al. 2012). Other‑Orientated Stimuli
Hwang et al. found that groups with high CU traits demon-
strated results in fMRI and behavioral measures consistent Of the 8 studies using ‘other-orientated’ emotional stimuli,
with reduced emotional responsiveness compared to results 5 (62%) showed those with high CU traits demonstrated less
from groups with low CU traits. However, De Wied et al. emotional responsiveness than those with low CU traits.
(2012) demonstrated inconsistent results within their study: Three studies included child samples, 2 (67%) of which
while groups with high CU traits demonstrated reduced found significantly reduced responsiveness in the high CU
responsiveness on physiological measures, there were no traits groups for at least one measure (Anastassiou-Had-
differences on measures of subjective experience and behav- jicharalambous and Warden 2008; Yoder et al. 2016). The
ioral responses. remaining study (Dadds et al. 2016) found similar emotional
responsiveness in the high and low CU trait groups. There
The Effect of Social Context on Emotional were 5 studies that included adolescent samples, 3 (60%) of
Responsiveness which demonstrated reduced emotional responsiveness for
the high compared to low CU trait groups on at least one
Next, we considered the effect of the social context embed- measure of responsiveness. Two (50%) of these studies used
ded in the emotion-eliciting stimuli. As shown in Tables 3 multiple measures of emotional responsiveness (De Wied
13
et al. 2012; Hwang et al. 2016), with both finding reduced measures of emotional responsiveness across the studies.
emotionality for high CU traits in physiological measures, First, the results were assessed to determine whether meth-
with mixed results in reports of subjective experience and odological variations correlated with different results in
behavioural measures. emotional responsiveness for high and low CU trait groups.
Physiological measures (i.e. peripheral physiological, fMRI)
Self‑Orientated Stimuli were expected to demonstrate dampened emotional respon-
siveness in high CU groups more frequently than more overt
Of the 5 studies using ‘self-orientated’ emotional stimuli, measures (i.e. behavioural and self-report). This effect was
2 (40%; Fanti et al. 2016; Schwenck et al. 2017) showed supported and it was concluded that physiological measures
reduced emotional responsiveness for high compared to low were more robust predictors of reduced emotional respon-
CU traits, while 3 (60%) (Helseth et al. 2015; Kimonis et al. siveness for high CU traits groups than others.
2017; Ragbeer 2015) found the opposite. Peripheral physiological measures were particularly
robust, with reduced emotional responsiveness for high CU
trait groups found in 4 out of 5 studies (80%) including these
Discussion measures. This finding aligns with previous literature, sug-
gesting that reduced physiological responding to emotional
Accurate etiological conceptualizations of how antisocial stimuli represents a specific biomarker of CU traits and psy-
behaviors develop are essential for clinical researchers to chopathic traits (e.g. Blair 2013; Moul et al. 2018). Devel-
develop effective early interventions and treatment. Recently, opmental theories of antisocial behavior suggest that this
such attempts have focused on children with CPs and high reduced physiological response to others’ emotional cues
CU traits—a group thought to show similar affective deficits is fundamental to the development of antisocial behaviors
demonstrated by adults with psychopathic traits. However, and attitudes (e.g. Moffitt and Caspi 2001; Raine and Yang
the evidence for this association is mixed, and yet no reviews 2006). The underlying theory is that, without aversive physi-
have been conducted with consideration made to the influ- ological responding (i.e. stress and distress), the classical
ence of varying experimental methods. This paper aimed conditioning processes associated with those feelings of see-
to systematically review literature reporting on emotional ing an individual in distress do not develop. This is believed
responsiveness for children with high vs. low CU traits to to impair the development of internalized social norms and,
test claims that high CU traits are synonymous with damp- more broadly, the development of prosocial behaviors (Hoff-
ened emotional responsiveness. man 2001).
The first specific aim was broad, with a focus on explor- In line with such theories, decreased neural activa-
ing whether dampened emotional responsiveness would be tion in core areas associated with emotional responsive-
more likely observed in samples of children with CPs and ness, particularly the amygdala, was expected. This was
high, rather than low, CU traits. Findings from this review also supported, with all 6 (100%) of the studies that used
did not support this supposition; rather, inconsistency was fMRI measures of emotional responsiveness testing amyg-
shown between studies reporting on emotional responsive- dala reactivity specifically. Five (83%) of these six studies
ness for children with CPs and varying CU traits. When showed that high CU traits were associated with reduced
child and adolescent studies were considered together, amygdala responsiveness when compared to children and
groups with high CU traits demonstrated reduced emotional adolescents with low CU traits. This finding is consistent
responsiveness in 13 of the 21 studies (62%) that met eli- with biological explanations of high CU traits and psychopa-
gibility criteria. When results were compared by age, chil- thy (e.g. Fanti et al. 2016; Viding and McCrory 2012). As
dren with high CU traits demonstrated dampened emotional the amygdala is involved with multiple stages of information
responsiveness compared to those with low CU traits in 3 processing and processing of affective information, reduced
out of 9 studies (33%), while adolescents showed this effect activity in children and adolescents with high CU traits has
for 10 out of 12 studies (83%). This finding indicates that been used to partly explain the emotion-processing deficits
low emotional responsiveness is not consistent across studies commonly seen (Blair 2013).
measuring this broad construct, which supports this review’s In addition to the amygdala, several other areas of the
decision to provide a more nuanced, structured review of brain were investigated in eligible studies. Three stud-
the literature. Further, the differences in results based on ies explored additional neural areas, with 2 (67%; Hwang
age indicate a need to consider developmental stage and its et al. 2016; Schwenck et al. 2017) demonstrating reduced
contribution to varying results. emotional responsiveness in high compared to low CU
In order to better understand the effect of emotional trait groups. They found that high CU trait groups demon-
components for children and adolescents with high com- strated lower reactivity in the ventromedial prefrontal cor-
pared to low CU traits, we considered the effects of different tex (Hwang et al. 2016) and the temporoparietal junction
13
(Schwenck et al. 2017): regions thought to regulate and on child samples, all of which showed similar emotional
suppress amygdala activity, and influence reinforcement responsiveness for CU trait groups. The remaining 5 studies
learning (e.g. Koenigs and Grafman 2009; Milad and Quirk (62%) were focused on adolescent samples and all found the
2012). These findings further confirm theories of physiolog- opposite effect: reduced emotional responsiveness in high
ically-based impairments affecting how children and adoles- CU compared to low CU groups. When comparing results
cents with CU traits process emotions. of child- and adolescent-focused studies, an age effect is also
The next step of the methodological based aims was to indicated: adolescents show reduced emotional responsive-
consider results based on the emotion-eliciting stimuli used. ness in high compared to low CU traits more frequently than
Based on the notion that emotional responsiveness should children. High CU traits have been associated with prob-
be stable across contexts (e.g. Blair 2005; Frick and Marsee lems orientating to areas that convey emotional informa-
2006), it was predicted that dampened emotional responsive- tion, such as the eye region on static images of faces (e.g.
ness in high CU trait groups would be similarly predicted Dadds et al. 2006), a commonly-used stimuli with neutral
by all emotional stimuli types. This effect was supported. or limited social context. These attention/orientation issues
All emotion-eliciting stimuli types demonstrated similar have been suggested as an explanation for reduced emo-
emotional responsiveness for participants with high and low tional responsiveness in those with high CU traits in pre-
CU traits. Imagery and interactive activities were equally vious studies (Marsh and Blair 2008; Szabó et al. 2017).
likely to demonstrate reduced emotional responsiveness in However, this effect was also found to be inconsistent across
the high CU trait group, with both demonstrating the effect studies in samples with high vs. low CU traits, particularly
in 5 out of 8 studies (62% each), and film with 2 out of 5 with child groups, providing further evidence of a complex
studies (40%). As none of the emotion-eliciting stimuli dem- association between CU traits and elements of emotional
onstrated a clear dominance in showing reduced reactivity responsiveness.
for high CU trait groups, each stimuli type was viewed as Other-orientated social stimuli were most likely to predict
similarly salient. reduced emotional responsiveness in high CU trait groups,
Next, emotional responsiveness was explored according with a total of 5 out of 8 studies (62%) demonstrating this
to the socio-emotional context of the emotion-eliciting stim- effect. Three were conducted with child samples. Two of
uli. Based on the plethora of work demonstrating low empa- these three studies (Anastassiou-Hadjicharalambous and
thy in children with high CU traits (e.g. Blair 2013; de Wied Warden 2008; Yoder et al. 2016) demonstrated reduced
et al. 2012; Decety and Svetlova 2012), it was predicted that emotional responsiveness in those children with high CU
other-orientated stimuli (e.g. stimuli that involved witness- traits compared to those with low CU traits. However, the
ing another person in distress) would more consistently dem- study conducted by Dadds et al. (2016) found the opposite.
onstrate diminished emotional responsiveness for those with Specifically, children with high CU traits were observed to
high compared to low CU traits. Emotion-eliciting stimuli be equally emotionally responsive as those with low CU
related to ‘self’ (e.g. participation in a frustration-inducing traits and healthy controls.
task) and stimuli that contained limited (neutral) information At the time of publication, this was an unexpected find-
about social context (e.g. images of facial expressions with ing, contrasting with the conclusions of previous studies
varying affect) were expected to demonstrate less predictable (e.g. Blair et al. 1999; Blair et al. 2001; Dadds et al. 2008).
results. This effect was also supported. Measurement issues were raised as a potential explana-
Studies using self-orientated social stimuli were least tion for this usual outcome. Only behavioural measures
likely to predict reduced emotional responsiveness for those of emotional responsiveness were used, raising the pos-
with high CU traits compared to low, showing this effect in sibility that children only appeared to be emotionally
2 out of 5 studies (40%). One explanation for these results responsive. Additionally, CU traits were measured using
is that self-orientated stimuli may have more personal sali- the UNSW System (Dadds et al. 2005), which while a
ence than other types, which might increase the chances of validated measure of CU traits—found to be particularly
greater emotional responsiveness. Perhaps a potential threat reliable for young children—controversially does not
to ‘self’ (e.g. through a frustration-induction task or removal include a specific item about whether the child ‘shows
of a desired toy) is sufficiently salient to trigger an emotional their feelings’. It is possible that exclusion of this item
response of similar magnitude to those with low CU traits, has unduly influenced the results in Dadds et al (2016).
which may support previous notions of the role of narcissis- Another explanation for the results was stimuli-based:
tic distress in these populations (e.g. Lau and Marsee 2013). the other-orientated stimulus used in the study was pri-
Neutrally-orientated social stimuli were more likely to marily ‘attachment-relationship’ related. Attachment
predict reduced emotional responsiveness in high compared relationships, maternal warmth in particular (see Wright
to low CU trait groups, with 4 out of 8 studies (50%) dem- et al. 2018), have received increasing attention in litera-
onstrating this effect. Three of the 8 studies (38%) focused ture as a potential protective factor for the development of
13
psychopathic traits into adulthood. They have also been In summary, the results from this review indicate a need
suggested to be more salient for eliciting emotions (e.g. to reconsider how emotionality and emotional responsive-
Pasalich et al. 2012). It is possible that young children ness is conceptualized within children and adolescents with
with high CU traits are more likely to demonstrate emo- high CU traits. Our main findings can be summarized in
tional responsiveness under attachment-related conditions, four points. The first is that dampened emotional respon-
though further studies with multiple validated measures of siveness in groups with high compared to low CU traits
CU traits are needed to confirm this speculation. was not consistently reported across studies. The second
When other-orientated responses in adolescent samples is that methodological variations, particularly how emo-
are examined, all studies—with exception to those using tional responsiveness was measured, influenced the likeli-
self-report measures (i.e. Martin-Key et al. 2017; Schwenck hood of dampened emotional responsiveness in high CU
et al. 2012)— demonstrate reduced responsiveness for those trait groups, with physiological measures the most robust
with high compared to low CU traits. One study that adopted predictors. The third is that the socio-emotional context of
multiple measurement methods did not show consistency the emotion-eliciting stimuli appeared to influence whether
between those methods. De Wied et al. (2012) showed that low emotional responsiveness would be demonstrated for
adolescents with high CU traits reported similar affective high CU trait groups, which was most likely with other-
experiences and demonstrated similar behavioral responses orientated contexts. The fourth is that children with high
compared to those with low CU traits, but with diminished CU traits appear to be more emotionally-responsive than
physiological responses. In this sense, those with high CU their adolescent counterparts. Overall, the results became
traits may appear, through observations and self-reports, to more homogenous with increased specificity: that is, when
be just as emotionally responsive as those with low CU traits socio-emotional context of the emotion-eliciting stimuli,
but still experience reduced physiological reactivity. This emotional measurement type and participant age are also
may also explain the discrepant findings of Martin-Key et al. considered. Accordingly, we propose several recommenda-
(2017) and Schwenck et al. (2012). An important question tions for future work.
is whether this emotional expression represents a genuine Firstly, studies documenting emotional responsiveness in
emotional experience or whether these expressions are fab- samples with CU traits should consider the socio-emotional
ricated, presumably for a self-orientated motivation. context of the emotion-eliciting stimuli used. Other-orien-
As referred to throughout, results also suggest differences tated stimuli are the most robust for predicting reduced emo-
in CU trait emotional responsiveness based on age. Chil- tional responsiveness in groups with high CU traits, which
dren with high CU traits demonstrated reduced emotional we believe speaks to a specific type of emotion-processing
responsiveness compared to those with low CU traits in 3 deficit. Deficits in the experience of other-orientated emo-
out of 9 studies (33%), while adolescents showed this effect tions likely signal a developmental trajectory marked by
for 10 out of 12 studies (83%), suggesting that emotional interpersonal problems and an increase in self-motivated
responsiveness may become more limited as children with behaviors (Fairchild et al. 2013; Frick and White 2008), con-
these personality traits grow older. These findings held when sistent with conceptualizations of empathy deficits in these
results were considered by the socio-emotional context of groups (e.g. Lui et al. 2016). Further exploration into emo-
the stimuli, with neutral, self-orientated and other-orientated tional responsiveness dependent on specific socio-emotional
stimuli showing a trend in which adolescents with high CU contexts would help to further delineate affective deficits in
traits were more likely than children with high CU traits to high CU trait groups.
demonstrate low emotional responsiveness. Secondly, the current review indicates that developmen-
Perhaps of greatest significance were the inconsistent tal influences on emotional responsiveness warrant further
findings in multiple measures of emotional responsiveness in consideration. Future studies should explore for age effects,
the adolescent samples to other-orientated socio-emotional especially using longitudinal designs to detail differences
stimuli. They may indicate that adolescents can learn to between younger children and adolescents, and also gender
respond in socially appropriate ways, while manifesting a effects. The majority of participants included in this review
limited physiological response. This explanation is consist- were male. Previous work has suggested that CU traits may
ent with developmental models of adolescence that empha- present differently dependent on the gender of the child (e.g.
size social development and the acquisition of socially- Essau et al. 2006; Raschle et al. 2018), indicating a need for
acceptable behaviors, which may extend to the expression further attention in this area. Our findings suggest an inter-
of emotion (e.g. Eisenberg 2000). While the link between esting age effect across studies: low emotionality was less
low emotional responsiveness and high CU traits appears likely to be demonstrated in child compared to adolescent
less consistent in children compared to adolescents, further groups. These findings could reflect a genuine difference
exploration of age effects is needed to better understand the between ages and correlation with low emotionality, but
etiology of these traits. further empirical studies are needed to test this tentative
13
theory. A delayed onset of reduced emotional responsiveness and weakness of this paper. This is a strength as we have
could identify a critical period for intervention. Conversely, been able to provide a very specific review of emotional
when results from other-orientated emotional stimuli are responsiveness based on the construct of CPs and varying
considered, both child and adolescent samples demonstrate CU trait status only. Literature exploring emotional respon-
consistently reduced responsiveness. In fact, the adoles- siveness in populations with CPs have frequently conflated
cent samples appear to lose some of the emotional deficits CU traits with the broader construct of psychopathic traits.
by demonstrating no affective differences in some studies As it is possible to attain a high score for overall psycho-
using self-reported experiences of emotion (e.g. De Wied pathic traits while achieving a low score on measures of CU
et al. 2012). This is especially interesting, as it may indi- traits, we excluded papers that did not report on CU traits
cate learning processes reflecting acquisition of complex specifically. Such literature has also explored emotional
theory of mind skills and learnt use of socially-appropriate responsiveness in populations with demonstrated high pro-
emotion-motivated behavior. It is believed that adults with active vs reactive aggression. Proactive aggression is asso-
psychopathic traits display emotion-based behaviors (such ciated with high CU traits (Bozsik et al. 2013; Lozier et al.
as providing self-reports of emotional experience) despite 2014) but it is not necessarily mutually inclusive (Eisenbarth
reduced emotional arousal (e.g. Carmen Pastor et al. 2003), et al. 2016; Yoder et al. 2016). Therefore, a range of studies
assumed to be for manipulation and personal gain (e.g. Frick that may have provided relevant information were excluded,
and Hare 2001; Frick and Moffitt 2010). Therefore, it is pos- due to ambiguity in reference to CU traits specifically.
sible that as children with early CU traits grow older, they This paper did not explore the influence of specific emo-
are more likely to show socially-appropriate behaviours in tions or impact of stimulus valence on emotional respon-
response to other-orientated emotional cues, but may not siveness. Due to the limited number of studies that aimed to
experience responsiveness on the other measures of emo- elicit a specific emotional response in participants, a review
tionality. Further research is needed to test such theories and exploring emotional responsiveness by affect or valence was
may provide further evidence for the necessity of inclusion not possible. Past research demonstrates that individuals
of physiological measures of emotion. with high CU traits have problems recognizing fear and sad-
Thirdly, we propose that multiple measures of emotional ness (e.g. Dadds et al. 2006; White et al. 2016) and possibly
responsiveness should be used to operationalize the con- other emotional states (Dawel et al. 2012), which indicates
struct more comprehensively. We found that physiological that further research into the influence of specific emotional
measures (i.e. fMRI and peripheral physiological arousal) states and emotional responsiveness would make an impor-
were most robust in predicting reduced emotional respon- tant contribution.
siveness in high CU trait groups. However, measures of Further, the findings of this paper must be taken within
emotional behavior and self-reports of subjective emotional the confines of a qualitative review. This paper aims to pro-
experience provide important insights into a more complete vide a synthesis of current literature reporting on specific
understanding of emotional experience and should not be dimensions of emotional responsiveness and children with
discounted. The fundamental goal of researchers in this area high CU traits, with the goal of raising questions and refo-
should be to understand how children with high CU traits cussing future research questions left unanswered about the
experience emotion and how this influences social learn- developmental trajectories of early CU traits. Limited num-
ing processes, including the internalization of prosocial bers of studies published in this area meant that a quantita-
rules and values. This can only be achieved when emotion- tive review is not yet possible to answer the questions posed
motivated behavior and self-reported experience is also con- in this review. Therefore, the generalizability of our findings
sidered (Fanti et al. 2016). Therefore, we recommend that are limited and must be observed within the context of the
future studies incorporate multiple measures of emotional findings from few studies.
responsiveness, with at least one physiological measure.
Strengths, Limitations and Recommendations Conclusion
To our knowledge, this paper is the first to systematically Individuals with psychopathic traits have long been associ-
review the empirical literature with the purpose of testing ated with notions of low emotionality, operationalized in this
whether the low emotionality demonstrated in adults with review as emotional responsiveness. Children with CPs and
psychopathic traits (e.g. Levenston et al. 2000; Verona et al. high CU traits are considered at higher risk of developing
2004) is also seen in youth with high CU traits. We believe psychopathic traits in adulthood, with patterns of dampened
we are the first to do so according to the effect of emotional emotional responsiveness deemed a key predictor for this
measurement, type of emotion-eliciting stimuli and social developmental trajectory. While there are some notable stud-
context of stimuli. The eligibility criteria are both a strength ies that support this thesis, some recent studies contradict this
13
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Is Callous Always Cold? A Critical Review of The Literature On Emotion and The Development of Callous-Unemotional Traits in Children

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