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Callosidad emocional desde la infancia hasta la

adultez
Claudia Patricia Quintero Cadavid
Especialista en Psiquiatría pediátrica
Docente ocsional
Universidad de Antioquia
 Introducción

•  Últimamente se ha prestado bastante atención a los problemas de

conducta en la infancia teniendo en cuenta brotes de violencia que se
han presentado a nivel mundial.

•  Existe además preocupación con la perpetuación de los mismos en la

adultez y su relación con el trastorno de personalidad antisocial.

•  Estos “problemas de conducta” se refieren a un patrón de

comportamiento repetitivo de rompimiento de normas, agresión e
indiferencia hacia los otros.

Blair, R. James R.; Leibenluft, Ellen; Pine, Daniel S. Conduct Disorder and Calllous-Unemotional Traits in Youth. The New England Journal of Medicine. December 4, 2014.
 •  El DSM-5, en su categoría “Trastornos disruptivos y del control de impulsos”
incluye el Trastorno Oposicionista Desafiante (TOD) y el Trastorno de
Conducta (TC), entre otros.

•  En CIE-11 se incluye en la categoría “Comportamiento disruptivo o trastornos

disociales”.

•  La mayoría de los niños con TC experimentan adversidad significativa en sus

vidas personales, y muchos muestran déficits severos en múltiples aspectos del
desarrollo y adaptación.

•  Algunos consideran que el TOD, el TC y el Trastorno de personalidad

antisocial se encuentran en un espectro psicopatológico.

•  El DSM 5 requiere evidencia de síntomas de TC para hacer un diagnóstico de

Trastorno de personalidad antisocial.

Lewis, M; y Rudolph, K. Handbook of developmental Psychopatology. Third edition. Springer. 2014

Thapar, A; Leckman, J; y Snowling, M. Rutter´s Child and Adolescent Psychiatry. Sixth edition. Wiley. 2015
 Epidemiología

• La prevalencia a lo largo de la vida del trastorno de conducta

es del 10%, con unas implicaciones económicas elevadas (6 a
16% para niños y 2 a 9% para niñas).
• Las investigaciones han mostrado que las trayectorias más
severas de comportamiento antisocial inician en la infancia
temprana.
• Hombres 3 a 7: Mujer 1 en la adolescencia.
• Mayor en niños maltratados.

Lewis, M; y Rudolph, K. Handbook of developmental Psychopatology. Third edition. Springer. 2014

Hyde, L. W; Waller, R; Trentacosta, C; Shaw, D; Neiderhiser, J; Ganiban, J; Reiss, D; Leve, L. Heritable and Nonheritable Pathways to Early Callous-Unemotional
Behaviors. AJP in Advance. doi: 10.1176/appi.ajp.2016.15111381

 Clasificación

•  Patrón repetitivo y persistente de comportamiento en el cual son

violados los derechos básicos de otros o las normas sociales
principales apropiadas para la edad, manifestado por la presencia
de al menos 3 de 15 comportamientos en los 12 meses anteriores*.

•  Estos comportamientos generan alteración significativa en el

funcionamiento personal, familiar, social o académico.

•  Se debe especificar si es de inicio en infancia o adolescencia, y si

existe presencia de emociones prosociales limitadas.

Martin, A; Bloch, M; y Volkmar, F. Lewis´s child and adolescent psychiatry: A comprehensive textbook. Fifth edition. Wolters Kluwer. 2018.
 Agresividad Destrucción de Engaño o robo Violaciones serias a las
propiedad normas
Acoso, amenazas o Iniciar incendios Ingresar a la casa, edificio Se queda hasta altas
intimidación a otros o auto de alguien horas de la noche sin
consentimiento de los
padres (<13 años)
Inicio de peleas físicas Destrucción de Mentir para obtener Se ha escapado de la casa
propiedad ajena beneficios o favores o al menos dos veces
para evitar obligaciones
Ha usado un arma Robar sin confrontar a la Escaparse de clases (< 13
victima años)
Crueldad física hacia
otras personas
Crueldad física hacia los
animales
Robos mientras se
confronta a la victima
Forzar a alguien a tener
relaciones sexuales

Martin, A; Bloch, M; y Volkmar, F. Lewis´s child and adolescent psychiatry: A comprehensive textbook. Fifth edition. Wolters Kluwer. 2018.
 Emociones prosociales limitadas
o callosidad emocional*
•  Falta de remordimiento y culpa.
•  Falta de empatía.
•  Despreocupación por el
desempeño.
•  Afecto deficiente o superficial.

•  Además responden poco al

castigo, muestran bajos niveles
de cortisol, buscan la novedad,
actividades peligrosas y
excitantes, tienen tendencia al
aburrimiento y tienen menos
rasgos de ansiedad que otros
jóvenes con los mismos niveles
de trastorno de conducta.

Martin, A; Bloch, M; y Volkmar, F. Lewis´s child and adolescent psychiatry: A comprehensive textbook. Fifth edition. Wolters Kluwer. 2018
 Comorbilidad

•  30 a 50% de los niños con TDAH también cumplen criterios para TC.
•  Depresión mayor, alrededor de 7 veces más que en la población
general
•  Abuso de sustancias, en adolescentes alrededor de 4 veces más.

Lewis, M; y Rudolph, K. Handbook of developmental Psychopatology. Third edition. Springer. 2014

Martin, A; Bloch, M; y Volkmar, F. Lewis´s child and adolescent psychiatry: A comprehensive textbook. Fifth edition. Wolters Kluwer. 2018
 Consideraciones del desarrollo
•  Los impulsos prosociales del niño se vuelven aparentes en el primer
año de vida, por ejemplo, a través de interacciones cooperativas y
compartir. Aumentan hasta los 3 años de edad y se empieza a notar
una disminución temporal.

•  Las emociones prosociales limitadas pueden ser identificadas en niños

hasta de 2 años de edad y están presentes en aproximadamente el
50% de los niños que cumplen criterios para TC.

•  Los comportamientos disruptivos son prevalente en los niños pero con

frecuencia se extinguen a medida que crecen.

Thapar, A; Leckman, J; y Snowling, M. Rutter´s Child and Adolescent Psychiatry. Sixth edition. Wiley. 2015
 Etiología y curso de desarrollo

•  Multifactorial.

•  Diferentes dominios:
•  Ejercicio de la autoridad por parte de los padres
•  Socialización con pares
•  Experiencias en la escuela
•  Riesgo en el vecindario

•  En el DSM 5, el TC tiene dos subtipos que se diferencian por la edad

de inicio, puede ser de inicio antes o después de los 10 años.

Lewis, M; y Rudolph, K. Handbook of developmental Psychopatology. Third edition. Springer. 2014

 Activación fisiológica de la respuesta
agresiva

Se han propuesto procesos que no son excluyentes y que trabajan en

combinación dentro de los individuos:

•  Bajos niveles de activación fisiológica que se asocian con irritabilidad

y motivan la voluntad y comportamientos de búsqueda de sensaciones
para estimular vías neuronales asociadas con la recompensa.

•  Nula sensibilidad a consecuencias negativas que pueden disminuir la

efectividad de esfuerzos de socialización diseñados para
redireccionar impulsos agresivos.

•  Hiperreactividad a la amenaza que se asocia con disregulación

emocional e ira, impulsando agresiones reactivas e impulsivas.

Lewis, M; y Rudolph, K. Handbook of developmental Psychopatology. Third edition. Springer. 2014

 Modelo de desarrollo
24 Conduct Disorder 479

Parece ser que una dinámica de coerción a los 2 a

Reactive Aggression Proactive Aggression
3 años promueve el pobre cumplimiento de
Early
Child Temperament
ordenes en el futuro y el comportamiento
Childhood
Angry Reactivity,
oposicionista percibido por los padres.
Impulsivity
A su vez, el poco seguimiento de normas por
Overcontrolling,
parte del niño a los 3 años predice relaciones
Sensitive
harsh parenting
caregiving
padre e hijo coercitivas en épocas posteriores.
No
Yes Middle
Angry Reactivity, Diversified and Childhood
Desistance Déficits en habilidades académicas, rechazo por parte
Impulsivity proactive aggression
de los pares, comportamiento antisocial, y pobre
Teacher/peer Poor monitoring, deviant
positive socialization
monitoreo por padres se combinaba para predecir
peer affiliation
Vs. rejection No filiación con pares desviados en la adolescencia
temprana.
Yes
Angry Reactivity, Diversified proactive aggression;
Desistance Impulsivity Expanding antisocial activities Adolescence

Fig. 24.1 Developmental sequence model

threats, they are more likely to counteraggress in approaches have demonstrated efficacy in reducing
Lewis, M; y Rudolph, K. Handbook of developmental Psychopatology. Third edition. Springer. 2014
response, making parents’ attempts to socialize aggression and antisocial activity (for compre-
 Del comportamiento antisocial a
la violencia
•  En la infancia temprana, practicas parentales que alteran la autorregulación relacionada

¿Cómo un adolescente
con la emoción son nucleares para el desarrollo social y emocional.

•  En la infancia media, las habilidades de manejo familiar que incluyen apoyo al

problemático se transforma
comportamiento positivo, establecimiento de limites y monitoreo, y construcción de relaciones
son pronósticos de comportamiento problema y competencia emocional.

•  En adolescencia y adultez joven los desenlaces se determinan por que tan

en un adulto peligroso?
adecudadamente el cuidador balancea la necesidad de autonomía con monitoreo y guía.

•  Hay filiación con pares negativos y cuando la marginalización es extrema se forman

pandillas.

Lewis, M; y Rudolph, K. Handbook of developmental Psychopatology. Third edition. Springer. 2014

 Heritable and Nonheritable Pathways to Early
Callous-Unemotional Behaviors
Luke W. Hyde, Ph.D., Rebecca Waller, Ph.D., Christopher J. Trentacosta, Ph.D., Daniel S. Shaw, Ph.D.,
Jenae M. Neiderhiser, Ph.D., Jody M. Ganiban, Ph.D., David Reiss, M.D., Leslie D. Leve, Ph.D.

Objective: Callous-unemotional behaviors in early child- Results: Despite limited or no contact with offspring,

•  Cohorte de 561 familias adoptivas, los niños fueron adoptados pocos

hood signal higher risk for trajectories of antisocial behavior
and callous-unemotional traits that culminate in later diag-
noses of conduct disorder, antisocial personality disorder,
días después del nacimiento.
and psychopathy. Studies demonstrate high heritability of
callous-unemotional traits, but little research has examined
biological mother antisocial behavior predicted early
callous-unemotional behaviors. Adoptive mother positive
reinforcement protected against early callous-unemotional
behaviors. High levels of adoptive mother positive rein-
forcement buffered the effects of heritable risk for callous-

•  Historia de comportamiento antisocial severo en las madres biológicas.

specific heritable pathways to early callous-unemotional unemotional behaviors posed by biological mother antisocial
behaviors. Studies also indicate that positive parenting pro- behavior.
tects against the development of callous-unemotional traits,

•  Observación del refuerzo positivo de la Conclusions:

but genetically informed designs have not been used to
madre
pathways
confirm that these relationships are not the product of gene- adoptiva a los 18The
The findings elucidate heritable and nonheritable
to early callous-unemotional behaviors.
results provide a specific heritable pathway to callous-
environment correlations. In a sample of adopted children
meses. unemotional behaviors and compelling evidence that
and their biological and adoptive mothers, the authors tested
parenting is an important nonheritable factor in the de-
novel heritable and nonheritable pathways to preschool

•  Evaluación a los 27 meses como predictores

callous-unemotional behaviors.
dereinforcement
emociones buffered prosociales
velopment of callous-unemotional behaviors. The finding
that positive heritable risk for
Method: In an adoption cohort of 561 families, history of callous-unemotional behaviors has important translational
limitadas. severe antisocial behavior assessed in biological mothers and
observations of adoptive mother positive reinforcement
implications for the prevention of trajectories to serious
antisocial behavior.

•  Concluyen que
at 18 months were examined as predictors of callous-
el behaviors
unemotional comportamiento
at 27 months. antisocial de la madre puede ser
AJP in Advance (doi: 10.1176/appi.ajp.2016.15111381)

predictor comportamientos de callosidad emocional. El refuerzo

positivo por
Seriousparte de las
antisocial behavior madres
is a key adoptivas
feature of the psychiatric
diagnoses of conduct disorder in youths and antisocial per-
remains era protector
limited, and contra
the marked heterogeneity estos
of individuals
with antisocial behavior may contribute to this problem (7). If
rasgos. sonality disorder in adults. Given their high cost, serious the etiologies of specific forms of antisocial behavior can
antisocial behaviors, such as aggression, violence, and rule be established, then more effective targeted, personalized
breaking, are a major public health concern. For example, a interventions can be developed.
recent study found that each adolescent diagnosed with To address heterogeneity in early-onset antisocial be-
conduct disorder cost society $14,000 more per year than havior, a specifier was added to the diagnosis of conduct
other high-risk adolescents (1). With a lifetime prevalence of disorder in DSM-5 to assess the presence of callous-
10% for conduct disorder (2), the financial implications of unemotional traits (“limited prosocial emotions”). Callous-
antisocial behavior are staggering. Additionally, these be- unemotional traits, characterized by low empathy, callousness,
haviors have broader, immeasurable occupational, health, and low interpersonal emotions, identify youths with severe,
social, and emotional costs for perpetrators, victims, and their chronic, and stable antisocial behavior (8). Studies demon-
families. Decades of research have shown that the most se- strating distinct neural correlates and higher heritability of
vere trajectories of antisocial behavior start in early child- antisocial behavior in the presence of callous-unemotional
hood (3–5). Thus, prevention programs have begun to target traits suggest that antisocial behavior with and without
 Pronóstico

•  Una vez se realiza el diagnóstico de TC, el pronóstico usualmente se

considera pobre.

•  Los que no evolucionan a Trastorno de personalidad antisocial tienen

otros problemas a largo plazo y se ha relacionado con persistencia de
psicopatología.

Blair, R. James R.; Leibenluft, Ellen; Pine, Daniel S. Conduct Disorder and Calllous-Unemotional Traits in Youth. The New England Journal of Medicine. December 4, 2014.
 Evolución a Trastorno de
personalidad antisocial
•  En un estudio longitudinal, 51% de los niños diagnosticados con TC
tenían un diagnostico de Trastorno de personalidad antisocial en la
adultez. Otro encontró un 35%, pero este llegaba a 71% entre
aquellos niños que mostraban los trastornos de conducta más severos.

•  Se cree que aquellos niños que son emocionalmente insensibles, tienen

poca empatía, y tienen ausencia de culpa o remordimiento están en un
Rasgos de emociones
riesgo aumentado para formas más severas y agresivas de
comportamiento antisocial, delincuencia en la adolescencia, y
prosociales limitadas
Trastorno de personalidad antisocial en la adultez, al compararlos
con niños sin estas características.

Lewis, M; y Rudolph, K. Handbook of developmental Psychopatology. Third edition. Springer. 2014

•  Los niños en el grupo de inicio temprano generalmente muestran un
mayor rango de ajuste social y dificultades de aprendizaje y tienen
mayor riesgo de persistir en comportamiento criminal y violento y
desarrollar trastorno de personalidad antisocial (Moffit y Caspi,
2001).

•  Sin embargo, otros autores argumentan que podrían ser más

importantes la severidad de la agresión, la existencia de
dificultades de aprendizaje cognitivas concurrentes, y las
experiencias de rechazo y victimización por parte de los pares.
 916 Chapter 65

Long-term
Antisocial Behavior Level Overall, ODD
outcomes, w
While the
vation in r
Christchurch
5% most ant
ODD/CD) a
who were N
comparative
5 10 15 20 25 30 35
heavy drug u
Age in Years
4%, leaving s
Not Antisocial (70%) Childhood Limited (7%) receiving sta
Adolescent Onset (15%) Early Onset Persistent (8%) Dividing c
Figure 65.1 Subtypes of antisocial behavior by longitudinal course (data hurtful pred
synthesis from several longitudinal studies). display mor
tantrums) ar
was significantly lower than the rate seen in the early-onset
Thapar, A; Leckman, J; y Snowling, M. Rutter´s Child and Adolescent Psychiatry. Sixth edition. Wiley. 2015
(but not fear
persistent group, it was not trivial, leading to a change in strong chara
 Disfunciones neurocognitivas
Conduct Disorder and Callous–Unemotional Tr aits

tently shown such distinctions for biologic fea-

•  Tres disfunciones neurocognitivastures18 or outcome.19

han sido ligadas Neuro

a aspectos
c o gni t i v e Dysf unc t ions
Anxiety
clínicos del TC, sin embargo
Promising work on outcomeseprediction and new
therapeutics uses a neuroscientific systems ap-
disorder

han encontrado proach,

igualmente
linking individualen
differences in behavior
to underlying mechanisms that shape brain func-
otros trastornos tion. This approach is used in the Research Do- ADHD
main Criteria project (www.nimh.nih.gov/research
-priorities/rdoc/index.shtml). Fundamentally, the ODD
purpose of the project is to identify neurocogni-
•  Empatía deficiente tive functions, for which the brain mechanisms
are understood, that can predict outcome or treat-
ment response. This approach requires research
conducted at both a brain-systems level, focused ASPD Conduct
•  Elevada sensibilidad a la on neural circuits, and a clinical level, focused on
individual differences in behavior contributing to Callous–unemotional
disorder

amenaza mental illness. traits

•  Dificultades en la toma de
decisiones
As described below, three neurocognitive dys-
functions have been linked to clinical aspects of
conduct disorder, thereby bridging brain-systems
and clinical data. This work has involved a range
of clinical entities, which often overlap in patterns
depicted in Figure 1. As discussed below, these
Figure 1. Overlap among Six Clinical Entities.
The size of each circle represents the relative preva-
lence of the clinical entity in the community. ADHD
denotes attention deficit–hyperactivity disorder, ASPD
antisocial personality disorder, and ODD oppositional–
defiant disorder.

dysfunctions are more clearly associated with cal-

lous–unemotional traits than the other entities tests in medicine. That is, such tests would augment
shown in Figure 1. Thus, the first dysfunction, rather than replace current psychiatric-assess-
deficient empathy, occurs relatively selectively in ment techniques by differentiating among patients
youth with these traits, whereas the second dys- with similar clinical presentations on the basis
function, heightened threat sensitivity, does not of the ability of the tests to predict a specific course
occur in this group. Rather, heightened threat or treatment sensitivity.
Blair, R. James R.; Leibenluft, Ellen; Pine, Daniel S. Conduct Disorder and Calllous-Unemotional Traits in Youth. The New England Journal of Medicine. December 4, 2014.
sensitivity occurs in patients who have conduct
disorder without callous–unemotional traits and Deficient Empathy
in patients with anxiety disorders. The third dys- Empathy influences behavior at many levels. Per-
 Empatía deficiente
The n e w e ng l a n d j o u r na l of m e dic i n

role in empathy, the am

•  Desde el punto de vista de desarrollo, Amygdala
Insula
Ventromedial
cuit encompassing the
cortex, and the associa
la empatía es critica para la prefrontal cortex
lobe. Heightened respo
socialización. Los niños aprender a be associated with gen
cessing of emotional
abstenerse de dañar a otros con el fin ripheral hemodynamic
de prevenir la angustia en la of developmental psyc
the amygdala is part of
“victima”. hypothalamus and pe
that mediates graded
from freezing to flight
increasing proximity o
•  Tiene fuerte asociación con las tivity in this circuit, a
emociones prosociales limitadas. creases the probability
ure 3 depicts the fu
Figure 2. Functional MRI Study of Face Processing. illustrating how threa
In the study, a child views a series of faces expressing various emotions. tivity and behavior.
To ensure attention to each face, the child is asked to identify the sex of Functioning in thi
•  Se ha relacionado con disfunción de the person. In healthy children, faces with fearful expressions elicit greater
amygdala activation than faces with neutral expressions. Faces with emo-
subgroups of youth w
la amígdala, imágenes de resonancia tional expressions other than fear elicit activation in other structures, in-
cluding the insula and prefrontal cortex. Amygdala activation in response to
subgroup has callou
shows reduced amygda
magnética funcional han encontrado fearful faces is reduced in youth with conduct disorder and callous–unemo- ing tasks that engage
disminución de la respuesta de la tional traits, as compared with either healthy youth or those who have con-
duct disorder without callous–unemotional traits.
or threat assessment.
lous–unemotional trai
amígdala a imágenes de rostros con tern, with atypically e
expresiones de miedo. predicts a poor response to typical socialization sponsiveness,38 a host
practices.1 increased risks of anx
Deficient empathy is related to amygdala dys- action to frustration o
function.3 The amygdala plays a central role in with conduct problem
aversive conditioning. Through this form of rein- unemotional traits, mu
forcement learning, persons learn to respond with ety disorders,40 show e
fear to a previously neutral action or object, after to threat, as compare
Blair, R. James R.; Leibenluft, Ellen; Pine, Daniel S. Conduct Disorder and Calllous-Unemotional Traits in Youth. The New England Journal of Medicine. December 4, 2014.
the action or object has been paired with the oc- free of psychopatholog
currence of an aversive event.28 Indeed, amygdala gression may be high
responses during prototypical forms of reinforce- responses occur in ta
 Soc Psychiatry Psychiatr Epidemiol (2012) 47:2045–2064
DOI 10.1007/s00127-012-0513-x

ORIGINAL PAPER

Callous–unemotional traits as a cross-disorders construct

Pierre C. M. Herpers • Nanda N. J. Rommelse •

Daniëlle M. A. Bons • Jan K. Buitelaar •

Floor E. Scheepers

•  Trastornos del espectro autista y Discapacidad intelectual se han

asociado aReceived:
bajos niveles de empatía y autorreflexión, entonces
25 July 2011 / Accepted: 14 April 2012 / Published online: 9 May 2012
! The Author(s) 2012. This article is published with open access at Springerlink.com

estarían asociados a niveles altos de rasgos de callosidad emocional?

Abstract
Purpose Callous–unemotional (CU) traits are currently
viewed as the defining signs and symptoms of juvenile
psychopathy. It is unclear, however, whether CU traits
•  No, realmente se ha encontrado muy baja correlación entre estos
have validity only in the context of conduct disorder (CD)
Results Inside youth with conduct problems, and CD
specifically, it seems that CU traits meet the Robins and
Guze criteria. As many of the reviewed studies included
youth with ODD and ADHD as well, there are indications
the same might be true for ODD and ADHD, although

trastornos y callosidad emocional. Los sujetos con TEA presentan

as proposed by Frick and Moffitt (A proposal to the DSM-
V childhood disorders and the ADHD and disruptive
probably to a lesser extent. In other disorders, CU traits
may be present as well, but their role is not firmly estab-

alteraciones en la empatía cognitiva.

behavior disorders work groups to include a specifier to the
diagnosis of conduct disorder based on the presence of
lished. As stand-alone construct, data are lacking or are
scarce on all of the above-mentioned criteria.
callous–unemotional traits, American Psychiatric Associ- Conclusions CU traits are a useful specifier in CD, and
ation, Washington, DC, 2010), or also outside CD, either in possibly also in disruptive behaviour disorders (DBDs)
combination with other forms of psychopathology or as a more generally. High CU traits outside DBDs exist but it is
•  Los estudios han encontrado que estos déficits se presentan
stand-alone construct.
Methods The current review systematically studied the
as yet unknown if there is a clinical need for defining CU
traits as a stand-alone construct.
principalmente en el sexo masculino en diferentes edades.
existent literature on CU traits in juveniles to examine their
Keywords Callous–unemotional traits ! Juvenile
validity inside and outside CD according to the framework
regarding the validity of a psychiatric diagnosis provided psychopathy ! Conduct disorder ! Validity
by Robins and Guze (Am J Psychiatry 126:983–987, 1970).

P. C. M. Herpers (&) ! N. N. J. Rommelse ! Introduction

D. M. A. Bons ! J. K. Buitelaar
Karakter Child and Adolescent Psychiatry University Centre, There is an increasing interest in the moderating role
Radboud University Nijmegen Medical Centre,
psychopathic traits may play regarding long-term outcome
Reinier Postlaan 12, 6525 GC Nijmegen, The Netherlands
e-mail: p.herpers@karakter.com and treatment effectiveness of disruptive behaviour [1–3].
Specifically, there is a widely held belief that psychopathy
N. N. J. Rommelse
e-mail: n.lambregts-rommelse@psy.umcn.nl has a poor outcome and is untreatable, although it seems
 Elevada sensibilidad a la
amenaza
•  La amígdala funciona en un circuito que incluye el tallo cerebral, la
corteza prefrontal, y la corteza de asociación en el lóbulo temporal.

•  Respuesta elevada de este circuito se asocia con dificultades

generales en el procesamiento de expresiones emocionales y ciertos
cambios hemodinámicos periféricos en diferentes entidades
psicopatológicas.

•  Además el circuito compuesto por la amígdala, el hipotálamo y la

materia gris periacueductal media la graduación de las respuestas a
la amenaza. Respuesta aumentada en este circuito, después de una
amenaza, aumenta la probabilidad de agresión reactiva.

Blair, R. James R.; Leibenluft, Ellen; Pine, Daniel S. Conduct Disorder and Calllous-Unemotional Traits in Youth. The New England Journal of Medicine. December 4, 2014.
 Conduct Disorder and Callous–Unemotional Tr aits

Hypothalamus

Amygdala
Periaqueductal
gray matter

Fight

Flee
Freeze

Figure 3. Relationships among the Proximity of a Threat, the Activity in a Particular Neural Circuit, and the Behavioral
Response to the Threat.
The neural circuit that is activated in response to a threat connects the amygdala, hypothalamus, and periaqueduc-
tal gray matter. The figure depicts a threat of increasing proximity, in the form of a bear that appears in the distance,
somewhat closer, or very close and about to attack. The brain circuitry activity increases as the threat draws closer.
Also shown are the different behaviors that are elicited as the proximity of the threat increases: from freezing to
flight to fight.

Blair, R. James R.; Leibenluft, Ellen; Pine, Daniel S. Conduct Disorder and Calllous-Unemotional Traits in Youth. The New England Journal of Medicine. December 4, 2014.
that require flexible responses to changing task button after exposure to one type of stimulus and
contingencies.44-46 not pressing the button after exposure to the other
Neuroscientific systems research shows that type of stimulus. In such research, the participant
 Dificultad en la toma de
decisiones
The ne w engl a nd jou r na l of medicine

cannot represent value and hence can

A the occurrence of rewards and punish
this context, receipt of an unexpect
elicits a brain response known as a po
0.20
diction error, indicating that an even
0.15 PE+ rewarding than expected. Conversely,
receive an expected reward elicits a

•  Aquellas personas que tienen

0.10
known as a negative prediction error,

Signal Change (%)

0.05 that an event is less rewarding than ex
You win 100 points such research, youth with conduct prob
0.00

dificultades para aprender como – 0.05

– 0.10
deficits in negative-prediction-error
manifested by deficient recruitme
striatum and ventromedial prefrontal

hacer elecciones que llevan a – 0.15

Thus, deficient brain functioning may
0 2 4 6 8 10 ated with deficient decision making.
Perturbed decision making occ
broadly than perturbed empathy or th

recompensas mas que a castigos Basal

ganglia
Ventromedial
prefrontal cortex
tivity. Decision-making impairments
youth who have conduct disorder wit
out callous–unemotional traits,44 in y

están en alto riesgo de B ADHD or oppositional–defiant disord

even in unaffected children of parents
duct problems or drug addiction.51 Thu

impulsividad, frustración y 0.20

0.15 PE–
decision making may be a substrate
types of conduct problems that frequen
including DSM diagnoses of conduc

agresión reactiva.
0.10 ADHD, oppositional–defiant disorder

Signal Change (%)

0.05 stance-use disorders.
You lose 100 points
0.00
Ge ne t ic a nd E n v i r onm e
– 0.05 R i sk s
– 0.10
Genetic and environmental risks intera
– 0.15
0 2 4 6 8 10 their effects on brain function. These i

•  Se ha encontrado que la corteza

are seen in behavioral research involv
adoptees, and families in natural expe
well as in molecular research on genet
genetic factors.

prefrontal ventromedial y el Figure 4. Format of a Functional MRI Study of Decision Making and Brain-
Activation Data as They Relate to Prediction-Error Signals in the Basal Ganglia.
Genetic Risk
Considerable data from genetic epid

estriado representan el valor de In this type of study, a research participant must learn to select one set of
stimuli (e.g., the elephant) by pressing a button and to avoid another set of
stimuli (e.g., the giraffe) by not pressing the button. Receipt of an unexpect-
ed reward elicits a positive prediction error (PE+), whereas failure to receive
studies have shown moderate-to-high
for clinical aspects of conduct problems
aggression52 and callous–unemotion

una acción e influencian la señal an expected reward, or a loss that is greater than expected, elicits a negative
prediction error (PE−). The plots show responses to feedback in the basal
ganglia during blood oxygen level–dependent functional MRI; the ventrome-
Other work in this area has suggeste
formance on neurocognitive tasks rela
pathy and decision making is also h

de predicción de error.
dial prefrontal cortex is also shown. The timing of feedback is represented by These findings point to an avenue for
the shaded column beginning at time zero. A PE+ occurs when the partici-
search that integrates a neuroscientif
pant wins more than expected after pushing a button at the sight of the ele-
phant. A PE− occurs when the participant loses more than expected after approach with genetic studies to eluc
pushing a button at the sight of the giraffe. These positive and negative pre- genetic factors shape clinical profile
diction errors generate the depicted reaction in the basal ganglia. effects on neurocognitive function. Ho
cause research in this area is only be

2212 n engl j med 371;23 nejm.org december 4, 2014

The New England Journal of Medicine

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Blair, R. James R.; Leibenluft, Ellen; Pine, Daniel S. Conduct Disorder and Calllous-Unemotional Traits in Youth. The New England Journal of Medicine. December 4, 2014.
 THE JOURNAL OF
CHILD PSYCHOLOGY AND PSYCHIATRY
Journal of Child Psychology and Psychiatry 49:4 (2008), pp 359–375 doi:10.1111/j.1469-7610.2007.01862.x

Research Review: The importance of callous-

unemotional traits for developmental models of
aggressive and antisocial behavior
Paul J. Frick and Stuart F. White
University of New Orleans, USA

•  Se han propuesto tres dimensiones para el constructo de psicopatía en

The current paper reviews research suggesting that the presence of a callous and unemotional inter-
adultos personal style designates an important subgroup of antisocial and aggressive youth. Specifically,
callous-unemotional (CU) traits (e.g., lack of guilt, absence of empathy, callous use of others) seem to
•  ¿Callosidad emocional?
be relatively stable across childhood and adolescence and they designate a group of youth with a
particularly severe, aggressive, and stable pattern of antisocial behavior. Further, antisocial youth with
•  Estilo CU
interpersonal arrogante y tramposo que incluye una visión narcisista de
traits show a number of distinct emotional, cognitive, and personality characteristics compared to
other antisocial youth. These characteristics of youth with CU traits have important implications for
uno mismo y comportamiento
causal models manipulador
of antisocial and aggressive behavior, for methods used to study antisocial youth,
and for assessing and treating antisocial and aggressive behavior in children and adolescents.
•  Estilo and
comportamental impulsivo e irresponsable que involucra pobre
Keywords: Callous-unemotional traits, aggression, antisocial behavior, conduct problems, children
adolescents, psychopathy.
planeación y tendencia al aburrimiento
There recently have been a number of reviews docu- traits has great potential for explaining the causes of
menting a large number of risk factors that have the most severe and aggressive patterns of antisocial
been associated with aggressive and antisocial behavior displayed by youth and that use of these
•  En adultos se ha encontrado que la primera dimensión es la más
behavior (Dodge & Pettit, 2003; Frick & Marsee,
2006; Loeber & Farrington, 2000; Raine, 2002).
traits to subtype antisocial youth could help to
integrate many of the past attempts for defining
especifica para aquellos individuos con altos rasgos psicopáticos
These risk factors include characteristics of the child
(e.g., neuropsychological deficits, autonomic irregu-
distinct groups of antisocial youth.

comparados con otros individuos antisociales. Esto se ha encontrado

larities, temperamental traits) and characteristics of
CU traits and developmental models of
the many social contexts (e.g., peer rejection, family
también en niños y adolescentes. psychopathy
dysfunction, neighborhood disorganization) that can
influence the child’s development. Such reviews have
CU traits are prominent in most conceptualizations
made it clear that theoretical models attempting to
of psychopathy in adults (Cleckley, 1976; Hare,
explain the development of antisocial and aggressive
1993). The construct of psychopathy in adults has
behavior and related psychiatric diagnoses (e.g.,
proven to designate a particular severe and violent
conduct disorder) need to be able to incorporate this
group of antisocial adults (Hemphill, 2007; Porter &
broad array of risk factors into their proposed causal
Woodworth, 2006) and a group of adults who seem
mechanisms.
to have distinct causal processes leading to their
It has also become increasingly clear that, within
antisocial behavior (Blair, Peschardt, Budhani,
youth who develop severe patterns of aggressive and
Mitchell, & Pine, 2006; Patrick, 2007). There is still
 THE JOURNAL OF
CHILD PSYCHOLOGY AND PSYCHIATRY
Journal of Child Psychology and Psychiatry 49:4 (2008), pp 359–375 doi:10.1111/j.1469-7610.2007.01862.x

Research Review: The importance of callous-

unemotional traits for developmental models of
aggressive and antisocial behavior
Paul J. Frick and Stuart F. White
University of New Orleans, USA

•  Los rasgos de callosidad emocional son lo suficientemente estables en

The current paper reviews research suggesting that the presence of a callous and unemotional inter-
niños y adolescentes
personal style designatespara designarlos
an important de tal
subgroup of antisocial manera
and aggressive loSpecifically,
youth. que implica su
callous-unemotional (CU) traits (e.g., lack of guilt, absence of empathy, callous use of others) seem to
persistencia durante
be relatively elchildhood
stable across desarrollo.
and adolescence and they designate a group of youth with a
particularly severe, aggressive, and stable pattern of antisocial behavior. Further, antisocial youth with
CU traits show a number of distinct emotional, cognitive, and personality characteristics compared to
other antisocial youth. These characteristics of youth with CU traits have important implications for
causal models of antisocial and aggressive behavior, for methods used to study antisocial youth,

•  Lo anterior es cierto, principalmente para la calificación por parte de

and for assessing and treating antisocial and aggressive behavior in children and adolescents.
Keywords: Callous-unemotional traits, aggression, antisocial behavior, conduct problems, children

los padres. and adolescents, psychopathy.

There recently have been a number of reviews docu- traits has great potential for explaining the causes of
menting a large number of risk factors that have the most severe and aggressive patterns of antisocial
been associated with aggressive and antisocial behavior displayed by youth and that use of these

•  Los rasgos de callosidad emocional en niños y adolescentes se han

behavior (Dodge & Pettit, 2003; Frick & Marsee, traits to subtype antisocial youth could help to
2006; Loeber & Farrington, 2000; Raine, 2002). integrate many of the past attempts for defining

asociado con problemas de conducta más severos, delincuencia o

These risk factors include characteristics of the child
(e.g., neuropsychological deficits, autonomic irregu-
distinct groups of antisocial youth.

agresión
larities, temperamental traits) and characteristics of
CU traits and developmental models of
the many social contexts (e.g., peer rejection, family
dysfunction, neighborhood disorganization) that can psychopathy
influence the child’s development. Such reviews have
CU traits are prominent in most conceptualizations
made it clear that theoretical models attempting to
of psychopathy in adults (Cleckley, 1976; Hare,
explain the development of antisocial and aggressive
1993). The construct of psychopathy in adults has
behavior and related psychiatric diagnoses (e.g.,
proven to designate a particular severe and violent
conduct disorder) need to be able to incorporate this
group of antisocial adults (Hemphill, 2007; Porter &
broad array of risk factors into their proposed causal
Woodworth, 2006) and a group of adults who seem
mechanisms.
to have distinct causal processes leading to their
It has also become increasingly clear that, within
antisocial behavior (Blair, Peschardt, Budhani,
youth who develop severe patterns of aggressive and
Mitchell, & Pine, 2006; Patrick, 2007). There is still
 THE JOURNAL OF
CHILD PSYCHOLOGY AND PSYCHIATRY
Journal of Child Psychology and Psychiatry 49:4 (2008), pp 359–375 doi:10.1111/j.1469-7610.2007.01862.x

Research Review: The importance of callous-

unemotional traits for developmental models of
aggressive and antisocial behavior
Paul J. Frick and Stuart F. White
University of New Orleans, USA

•  Estos rasgos son particularmente importantes para designar una vía

The current paper reviews research suggesting that the presence of a callous and unemotional inter-
de desarrollo única
personal style hacia
designates comportamiento
an important antisocial
subgroup of antisocial and severo
aggressive youth. y agresión.
Specifically,
callous-unemotional (CU) traits (e.g., lack of guilt, absence of empathy, callous use of others) seem to
be relatively stable across childhood and adolescence and they designate a group of youth with a
particularly severe, aggressive, and stable pattern of antisocial behavior. Further, antisocial youth with
CU traits show a number of distinct emotional, cognitive, and personality characteristics compared to

•  La presencia de estos rasgos para estar más asociada con la

other antisocial youth. These characteristics of youth with CU traits have important implications for
causal models of antisocial and aggressive behavior, for methods used to study antisocial youth,

trayectoria de inicio en la infancia.

and for assessing and treating antisocial and aggressive behavior in children and adolescents.
Keywords: Callous-unemotional traits, aggression, antisocial behavior, conduct problems, children
and adolescents, psychopathy.

There recently have been a number of reviews docu-
menting a large number of risk factors that have
been associated with aggressive and antisocial
behavior (Dodge & Pettit, 2003; Frick & Marsee,
2006; Loeber & Farrington, 2000; Raine, 2002).
These risk factors include characteristics of the child
(e.g., neuropsychological deficits, autonomic irregu-
larities, temperamental traits) and characteristics of
the many social contexts (e.g., peer rejection, family
dysfunction, neighborhood disorganization) that can
influence the child’s development. Such reviews have
made it clear that theoretical models attempting to
explain the development of antisocial and aggressive
behavior and related psychiatric diagnoses (e.g.,
conduct disorder) need to be able to incorporate this
broad array of risk factors into their proposed causal
mechanisms.
It has also become increasingly clear that, within
youth who develop severe patterns of aggressive and
traits has great potential for explaining the causes of
the most severe and aggressive patterns of antisocial
behavior displayed by youth and that use of these
traits to subtype antisocial youth could help to
integrate many of the past attempts for defining
distinct groups of antisocial youth.
CU traits and developmental models of
psychopathy
CU traits are prominent in most conceptualizations
of psychopathy in adults (Cleckley, 1976; Hare,
1993). The construct of psychopathy in adults has
proven to designate a particular severe and violent
group of antisocial adults (Hemphill, 2007; Porter &
Woodworth, 2006) and a group of adults who seem
to have distinct causal processes leading to their
antisocial behavior (Blair, Peschardt, Budhani,
Mitchell, & Pine, 2006; Patrick, 2007). There is still
Conclusiones

•  De acuerdo a los criterios diagnóstico del DSM 5, los sujetos diagnosticados

con trastorno de conducta configuran un grupo muy heterogéneo.

•  Sin embargo, el diagnóstico de Trastorno de conducta se asocia con

persistencia de psicopatología a lo largo de la vida.

•  Aquellos sujetos que presentan emociones prosociales limitadas pueden

presentar asociación con trastorno de personalidad en la adultez.

•  La callosidad emocional se asocia con mayor persistencia de síntomas de

trastorno de conducta y severidad de los mismos.

•  La utilidad de este especificador es la implementación de medidas en el

tratamiento que permitan disminuir estos rasgos y mejorar el pronóstico en la
adultez.
Bibliografía
•  Blair, R. James R.; Leibenluft, Ellen; Pine, Daniel S. Conduct Disorder and Calllous-Unemotional Traits
in Youth. The New England Journal of Medicine. December 4, 2014.
•  Hyde, L. W; Waller, R; Trentacosta, C; Shaw, D; Neiderhiser, J; Ganiban, J; Reiss, D; Leve, L.
Heritable and Nonheritable Pathways to Early Callous-Unemotional Behaviors. AJP in Advance. doi:
10.1176/appi.ajp.2016.15111381.
•  Lewis, M; y Rudolph, K. Handbook of developmental Psychopatology. Third edition. Springer. 2014.
•  Martin, A; Bloch, M; y Volkmar, F. Lewis´s child and adolescent psychiatry: A comprehensive
textbook. Fifth edition. Wolters Kluwer. 2018.
•  Jambroes, T; et al. The clinical usefulness of the new LPE specifier for subtyping adolescents with
conduct disorder in the DSM 5. Eur Child Adolesc Psychiatry. January 2016.
•  Cheepers, F; Buitelaar, J; y Matthys, W. Conduct Disorder and the specifier callous and unemotional
in the DSM-5. Eur Child Adolesc Psychiatry (2011) 20:89-93.
•  Hyde, L; et al. Heritable and Nonheritable Pathways to Early Callous-Unemotional Behaviors. AJP
in Advance. doi: 10.1176/appi.ajp.2016.15111381)
•  Wright, N; et al. Maternal sensitivity to distress, attachment and the development of callous-
unemotional traits in young children. The Journal of Child Psychology and Psychiatry. 2018.
•  Sharp, C; et al. Callous-Unemotional Traits are associated with deficits in recognizing complex
emotions in preadolescent children. Journal of Personality Disorders, 29(3), 347-359, 2015.
•  Viding, E; et al. Antisocial behaviour in children with and without callous-unemotional traits. Journal
of the Royal Society of Medicine. 2012:105:195-200.
 Comportamiento antisocial
•  Abierto (pataletas, agresión) vs encubierto (mentir y robar)
•  Agresión proactiva (premeditada, ataques de predadores) vs reactiva
(explosión reactiva cuando es provocado)
•  Agresión física (morder, golpear) vs relacional (acoso, insultos
verbales)
•  Comportamiento antisocial en casa vs en colegio

•  Se ha reportado que la persistencia en la adultez no se relaciona con

un síntoma particular sino por la severidad, diversidad y duración de
los síntomas en la infancia (Lee Robins 1966).
•  En la publicación clásica de 1993, Moffit y cols describieron 3 grupos
diferentes del estudio Dunedin
•  “inicio temprano persistente a lo largo de la vida”
•  “limitado a la adolescencia”
•  “no antisocial”

Thapar, A; Leckman, J; y Snowling, M. Rutter´s Child and Adolescent Psychiatry. Sixth edition. Wiley. 2015
 Oppositional and conduct disorders 917

Table 65.2 Factors predicting poor outcome.

Onset Early onset of severe problems, before age 8

Phenomenology Antisocial acts which are severe, frequent, and varied; physical aggression; premeditated acts;

Comorbidity Hyperactivity and attention problems; callous-unemotional traits

Intelligence Lower IQ

Family history Parental criminality; parental alcoholism

Pregnancy Possibly maternal anxiety during pregnancy, smoking

Parenting Harsh, inconsistent parenting, with high criticism, low warmth, low involvement, and low supervision;
interparental violence

Wider environment Low income family in poor neighborhood with ineffective schools.

The risks were amplified at age 65 follow-up (Maughan et al., presence of inattention and hyperactivity (Thapar et al., 2013),
2013) (Table 65.2). callous unemotional traits (Viding et al., 2008) or high levels
of physical aggression (Burt, 2009) and also if the antisocial
Service use and cost behavior is pervasive across situations (Arsenault et al., 2003).
Both in childhood and in the longer term into adulthood, indi- Conversely, where these factors are absent, genetic contribution
viduals with ODD/CD are expensive to society. In childhood, is low (Silberg et al., 1996; Viding et al., 2008).
they and their families are in contact with multiple agencies.
Use of social services is significantly higher than for children Specific genes
with emotional disorders. Utilization of specialist child mental Main effects of particular genotypes for antisocial behavior,
health and social services is significantly higher among children as opposed to ADHD, have not been particularly evident and
with unsocialized CD than socialized CD (Shivram et al., 2009). isolated findings have not consistently been replicated; no
Apart from service use, substantial costs fall on the families in consistent linkage regions have been identified (Plomin et al.,
terms of lost opportunity to work (Romeo et al., 2006). Over the 2013). One approach has been to look at systems of genes, rather
Thapar, A; Leckman, J; y Snowling, M. Rutter´s Child and Adolescent Psychiatry. Sixth edition. Wiley. 2015
longer term, by their mid-20s, children who had ODD/CD cost than individual genes. Using this approach, Bentley et al. (2013)
an average 10 times as much as controls (Scott et al., 2001) which found eight single-nucleotide polymorphisms that accounted
 •  De manera general, aquellos niños con TC que también tienen rasgos
de callosidad emocional tienen pobre pronostico.

Thapar, A; Leckman, J; y Snowling, M. Rutter´s Child and Adolescent Psychiatry. Sixth edition. Wiley. 2015