Forensic Science International 224 (2013) 17

Contents lists available at SciVerse ScienceDirect

Forensic Science International

journal homepage: www.elsevier.com/locate/forsciint

Review article

Youth psychopathy: Differential correlates of callous-unemotional traits,

narcissism, and impulsivity
Johanna Feilhauer a,*, Maaike Cima b
a
b

Maastricht University, Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, P.O. Box 616, 6200 MD Maastricht, The Netherlands
Tilburg University, Department of Development-, Clinical-, and Cross-Cultural Psychology, P.O. Box 90153, 5000 LE Tilburg, The Netherlands

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 28 July 2011
Received in revised form 22 September 2012
Accepted 8 October 2012
Available online 11 November 2012

Research supports the validity of the dimensional approach to psychopathy in both children and adults.
The occurrence of severe aggressive and antisocial behavior in combination with callous-unemotional
traits (CU traits) designates a group of children that is particularly at risk to develop psychopathy.
However, most studies did not investigate the role of the remaining psychopathy dimensions (i.e.
narcissism and impulsivity) in comparison. The present text reviews the newest developments in the
dimensional study of psychopathy in relation to cognition, behavior and affect in clinical and detained
child and adolescent samples. Findings support the role of the callous-unemotional dimension (CU
traits) in the development of psychopathy. Additionally, they also underscore the importance of the
narcissistic and impulsive dimensions for the understanding of psychopathy in children and adolescents
and for the identication of different psychopathy proles. Understanding differential correlates of the
underlying dimensions of psychopathy is an important step in formulating interventions for those most
at risk.
2012 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Psychopathy dimensions
Cognitive functioning
Aggression
Cortisol
Response inhibition

Contents
1.

2.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1.
The psychopathy concept . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Child and adolescent measures of psychopathy dimensions
1.2.
Cognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.3.
Intelligence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.3.1.
Response inhibition . . . . . . . . . . . . . . . . . . . . . . . . .
1.3.2.
Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.4.
1.4.1.
Aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Affect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.5.
Cortisol and emotion processing. . . . . . . . . . . . . . .
1.5.1.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction
Psychopathy is a complex personality disorder with affective,
interpersonal and behavioral characteristics. Psychopaths are
emotionally callous, narcissistic and manipulative, antisocial and

* Corresponding author. Tel.: +31 43 3881600; fax: +31 43 3884155.

E-mail addresses: J.Feilhauer@maastrichtuniversity.nl (J. Feilhauer),
m.j.cima@uvt.nl (M. Cima).
0379-0738/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.forsciint.2012.10.016

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.

1
2
3
3
3
3
4
4
5
5
5
6

impulsive. The concept of psychopathy is dened as a factorial

construct, which captures these aspects [1,2]. The majority of
studies concentrated on a taxonic, categorical approach, viewing
psychopaths as a discrete class, comparing them to nonpsychopaths based on total psychopathy scores, thereby neglecting its dimensional structure. More recently, a dimensional
approach to psychopathy, in which factors are viewed as
dimensions existing along a continuum, is promoted [35]. This
view of a dimensional latent structure of psychopathy suggests
that differences in psychopathic traits between individuals

J. Feilhauer, M. Cima / Forensic Science International 224 (2013) 17

describe differences in degree (i.e. being more or less psychopathic

on a continuum) rather than taxonic differences (i.e. psychopath
versus nonpsychopath [6]).
Over the last decades research has extended the concept of
psychopathy to children and adolescents. The occurrence of
callous-unemotional traits (CU traits), i.e. a lack of guilt and an
inability to show empathy and emotions [7] has received much
attention in this context. Children with severe conduct problems
and CU traits show a substantial number of characteristics
associated with adult psychopathy [7,8]. First longitudinal
evidence shows that CU traits predict severe conduct problems
and remain fairly stable into early adulthood [9]. Likewise, twin
studies identied a profound, unique genetic inuence on
psychopathic personality dimensions in general [1012]. Twin
studies of CU traits in children with conduct problems found high
levels of these traits to be under extreme strong genetic inuence
at age 7 and 9. No signicant shared environmental inuences on
CU traits were found [13,14]. Based on these and related ndings,
children with severe conduct problems and CU traits are believed
to be most of all at risk to develop psychopathy in adulthood [15].
However, the contribution of the remaining psychopathy dimensions is still unclear. Whereas adult research long focused on the
use of global psychopathy indices, research in children and
adolescents mainly focuses on the role of CU traits. Given that
psychopathic individuals can score differently on the underlying
psychopathy dimensions, it seems reasonable that the solitary use
of global indices or CU traits might shadow relevant differential
correlates of psychopathy [16,17]. Understanding these correlates
is an important step in expanding our understanding of
psychopathy, the identication of individual dimensional proles,
and the invention of successful treatment plans. Given that
behavioral disorders constitute the largest part of disorders in child
and adolescent psychological and psychiatric settings, diagnostical
and treatment improvements seem highly desirable.
The present text reviews recent ndings and developments
concerning the dimensional approach to youth psychopathy and
its correlates. However, a wide range of possible correlates exist.
Examining psychopathy dimensions from one approach, will give a
one-sided view. Therefore, the present text concentrated on three
important areas of cognitive, behavioral and affective aspects. We
thereby hope to promote our understanding of psychopathy and to
enhance the integration of the dimensional approach. We aim to
shed light on what is known to date and provide suggestions for
further research.
To identify relevant published studies a literature search was
completed using Web of Science1, PsychINFO and PubMed. The key
terms psychopathy dimensions, PCL-R:YV and APSD were each
paired with the terms relating to the elds of interest (i.e.,
intelligence, response inhibition, aggression [reactive/proactive],
cortisol). Reference sections were examined in detail. The

following limits were selected: English (language), peer-reviewed

journals (publication type).
Inclusion criteria for the present review were: assessment of
psychopathy dimensions (total and factor/subscale scores) with
either the Psychopathy Checklist: Youth Version (PCL:YV) or the
Antisocial Screening Device (APSD; [18,19]), child and/or adolescent participants (N > 10, age 18) with severe behavioral
problems (clinically referred or detained). A total of 8 published
papers were examined (see Table 1). In two articles samples
included detained youth, but the studies made use of the
Psychopathy Checklist (PCL-R). The scarcity of literature underscores the conceptual novelty of the more differentiated dimensional approach to psychopathy as stated here. All identied
articles are discussed. Furthermore, links to the adult literature are
presented.
1.1. The psychopathy concept
The classical clinical conceptualization describes psychopathy
as a constellation of affective, interpersonal and behavioral
characteristics. According to Cleckleys [86] classical observations,
the affective characteristics are dened by callousness, a lack of
empathy and remorse together with short-lived emotions. The
interpersonal characteristics of the psychopath include narcissism,
good intelligence, verbal and manipulative abilities, supercial
charm, egocentricity and glibness. Behaviorally, psychopaths were
described as impulsive, irresponsible, prone to boredom, novelty
seeking and antisocial. Based on Cleckleys description and
empirical research the psychopathy checklist-revised (PCL-R)
was developed [20]. Factor analyses of the PCL-R items obtained
two moderately correlated psychopathy dimensions, also named
factors. Factor 1 (F1) represents the affective/interpersonal
personality components of psychopathy. They are viewed as the
core characteristics of psychopathy. Factor 2 (F2) represents the
impulsive/antisocial behavioral aspects of psychopathy. However,
there is still substantial debate about how many dimensions best
describe the disorder. Two to four factor models have been
suggested. In recent research at least three dimensions consistently emerge [1,16]. In adults they describe an arrogant and deceitful
narcissistic/interpersonal dimension, a callous-unemotional/affective decient dimension, and a third dimension representing
irresponsible, impulsive behavior. In this model antisocial behavior is considered more as a result of the three dimensions than as
part of the psychopathy construct [21].
The different psychopathy dimensions nd support in differing
psychophysiological and brain correlates. In detained samples, the
affective/interpersonal dimension has been linked to decits in
fear-potentiated startle and reduced electrodermal activity
[22,23]. The impulsive/antisocial dimension was more related to
electrodermal hyperreactivity [24]. On brain level amygdala

Table 1
Overview of the literature search.

Cognition
Salekin et al. [16]
Feilhauer et al. [46]
Behavior
Barry et al. [60]
Fite et al. [62]
Vitacco et al. [17]
Flight and Forth [33]
Affect
Holi et al. [64]
Burke et al. [9]

Sample

Age, N

Methodology

Topic

Detained youth
Detained youth

1118, 122
1517, 53

PCL:YV (three factor model)

PCL:YV (two factor/four facet model)

Intelligence
Response inhibition

Aggressive children
assigned to an intervention program
Clinical sample, behavioral problems
Detained youth
Detained youth

912, 160

APSD (three factor model)

Reactive and proactive

aggression

612, 105
1217, 122
1620, 51

APSD (three factor model)

PCL:YV (four facet model)
PCL:YV (four facet model)

Detained youth
Clinically referred youth

1622, 20
716, 66124

PCL-R (two factor model)

PCL-R (two factor model)

Note: PCL:YV, psychopathy checklist: youth version; APSD, antisocial process screening device; PCL-R, psychopathy checklist-revised.

Basal cortisol

J. Feilhauer, M. Cima / Forensic Science International 224 (2013) 17

damage has been related to the emotional decits captured by the

callous-unemotional/affective dimension leading to decits in the
interpretation of emotional stimuli like facial expressions, fear or
sadness in others, and emotional learning in the form of stimulusreinforcement associations [2527]. Also, the orbitofrontal cortex
(OFC) and a distorted communication between the OFC, the
amygdala and other paralimbic structures are believed to be
related to difculties in basic forms of emotional learning and
decision making in psychopathy ([28]; see e.g. [29] for a more
detailed discussion). Different genetic polymorphisms affect
amygdala reactivity and its interaction with the OFC [30,31]. A
genetic risk for Psychopathy might therefore depend on the
number of polymorhisms that cause a reduced emotional and
amygdala functioning [26].
1.2. Child and adolescent measures of psychopathy dimensions
In children and adolescents the three dimensions are often
described as narcissism, callous-unemotional-traits (CU traits) and
impulsivity [32], and are combined in the term psychopathic traits
[33]. [The four factor model adds an antisocial dimension capturing
the deviant lifestyle [2]. The two factor model combines the callous
and narcissistic personality dimensions as well as the impulsive
and antisocial dimensions, named callous/narcissistic dimension
and impulsive/antisocial dimension in the remainder of this article
[20].]
Given the evidence for the importance of psychopathic traits
to the downward extension of the psychopathy construct,
efcient reliable and valid measures are needed. Psychopathic
traits are generally assessed either by semi-structured clinical
interviews, so called expert ratings, or with the help of either
self-report or informant questionnaires. To date the vast
majority of studies assessing psychopathic traits in conduct
disordered children and adolescents made use of either the
Psychopathy Checklist: Youth Version (PCL:YV) or the Antisocial
Screening Device (APSD).
The Psychopathy Checklist: Youth version, a downward extension
of the PCL-R interview has been developed for the use with
adolescent samples (PCL:YV; [18]). Like the adult version of the
Psychopathy Checklist (PCL-R; [20]), it consists of 20 items, which
can be subdivided into two to four factors. Ratings on the separate
items are based on a semi-structured interview together with the
subjects interpersonal presentation and collateral information
consisting of clinical and legal reports. The PCL:YV is designed for
the use with institutionalized adolescent delinquents (age 1218).
It is difcult to use without collateral information. The interview
tabs topics as the youths family background, past relationships,
friendships, employment history, alcohol and drug use, school,
delinquent behavior and future plans. The PCL:YV has adequate
psychometric properties [18].
The Antisocial Process Screening Device (APSD; [19]) is typically
used in samples of young children, aged 613 years. It comes in
teacher and parent versions. Additionally, a self-report version for
the use with adolescents has been developed, which is used in
juvenile offenders [34,35]. The APSD consists of 20 items. Like the
PCL:YV it is originally based on the PCL-R. The items map onto 15
PCL-R items. Items not relevant for children and adolescents were
excluded. Research indicates a three-factor model for the APSD
[32]. However, the factor composition defers form the composition
of the PCL-R factors [18]. The APSD factors are named Narcissism
(NAR), Callous/Unemotional (CU), and Impulsivity (IMP). Early
research with the APSD utilized a two-factor model [7]. The APSD
has to deal with a number of psychometric shortcomings like very
limited numbers of items measuring each factor. Internal
consistency measures were generally adequate for the APSD total
in the range of 0.7881, and lower for the different factors, ranging

form 0.50 to 0.68, with the CU factor being the lowest and IMP
being the highest [34,35].
The present review concentrates on studies which utilized one
of these reliable and valid instruments. Past studies used a variety
of different samples. This made an integration of the ndings
difcult Therefore, we concentrate on studies using clinical or
detained child and adolescent samples with severe behavioral
problems. It is still questioned how many dimensions best describe
the psychopathy concept. Therefore, all approaches are integrated
in the present review.
1.3. Cognition
1.3.1. Intelligence
Antisocial behavior in children and adolescents has long been
related to intellectual, in particular verbal, and executive (frontal
lobe) functioning decits [36,37]. Verbal intellectual decits are
even viewed as one of the most stable predictors of antisocial
behavior [37,38]. It is, therefore, not surprising to nd positive
associations between the impulsive dimension of psychopathy and
intellectual decits. The associations of the callous-unemotional
and the narcissistic dimensions with intellectual decits are less
clear.
According to Cleckley [86] psychopaths present with good
intelligence, particularly verbal, creative, practical and analytic
abilities. This is reasonable as psychopathic characteristics like
deceit and manipulative behavior seem to warrant a certain
amount of intelligence. One could easily think of good verbal,
forethought and planning abilities. Salekin et al. [16] examined the
relation between the psychopathy dimensions and intelligence in a
detained youth sample (N = 122, age 1118) using the PCL:YV
(three factor model). The disturbed callous-unemotional dimension
was negatively associated with verbal intelligence and with
measures of creativity, practicality, and analytic thinking. The
narcissistic dimension on the other hand, was positively associated
with all these intellectual abilities. The impulsive dimension was
positively associated with measures of creativity, practicality, and
analytic thinking, but not with verbal abilities [16]. Thus, whereas
high levels on the callous-unemotional dimension were related to
poorer intellectual abilities, high levels on the narcissistic
dimension were related to better intellectual abilities. High levels
on the impulsive dimension were related to higher creativity,
practicality and better analytic thinking, but not to verbal abilities.
Although not conclusive, these ndings partly support Cleckleys
traditional conceptualization [16]. Similar patterns of results come
from the adult literature [39], suggesting that the presented
associations are not age dependent. Thus, studies using the PCL-R
and PCL:YV point to a specic association between narcissism and
good intellectual, mainly, verbal, abilities.
1.3.2. Response inhibition
Like decits in verbal intelligence, neuropsychological decits,
for example decits in executive functioning, are well documented
in children and adult antisocial behavior [36,40]. Executive
functions control and regulate information processing in the brain
and are necessary for socially appropriate behavior, self-control,
responsiveness to punishment, and ethical behavior [41]. The
question whether psychopaths present with executive functioning
decits is not conclusively answered yet. Impairments have been
shown in executive functions that are related to the orbitofrontal/
ventromedial frontal cortex and the limbic system, i.e. the
amygdala (e.g. risk related decision making and affect regulation).
Other executive functions related to the dorsolateral prefrontal
cortex, e.g. planning and inhibition, seem to be less impaired
[41,42]. Given that psychopaths are known for their goal-directed,
planned and manipulative behavior they might be able to control

J. Feilhauer, M. Cima / Forensic Science International 224 (2013) 17

their behavioral responses, i.e. present with normal or even

advanced response inhibition abilities and show less impulsivity.
Two studies investigated response inhibition with the use of
neuropsychological tests in youth and adult psychopaths. They
found psychopaths to be even more impulsive than nonpsychopaths based on their PCL:YV/PCL-R total scores [43,44].
However, damage to the dorsolateral cortex, which would be
associated with poor planning and inhibition abilities, is generally
related to antisocial behavior, i.e. the impulsive and antisocial
dimensions [41,45]. It seems, therefore, reasonable that poor
response inhibition as one aspect of impulsivity would be mainly
attributable to high scores on these dimensions. A recent study in
detained youth (N = 53, age 1517) found high levels on the
impulsive/antisocial dimension to be related to poor response
inhibition on a classical response inhibition task (PCL:YV, two
factor model; [46]). High levels on the callous/narcissistic dimension, on the other hand, were related to better response inhibition,
though not signicantly. In particular the callous and antisocial
dimensions (PCL:YV, four factor model) accounted for the obtained
opposing associations. The narcissistic and impulsivity dimensions
were unrelated to response inhibition [46]. A related study in
college students, using the Psychopathy Personality Inventory (PPI,
a two factor psychopathy measure developed for community samples),
found the callous/narcissistic dimension to be unrelated to
response inhibition, as assessed with neuropsychological testing,
and positively related to other measures of executive functioning
[47]. The impulsive/antisocial dimension, on the other hand, was
related to poorer performance on all general executive functioning
tasks and response inhibition [47]. Furthermore, a recent study in
adult offenders found the impulsive and antisocial dimensions
(PCL-R, two and four factor model) to be related with high scores on
a self-report questionnaire of impulsivity, whereas there was
evidence for reduced impulsivity in relation to the callous and
narcissistic dimensions [48]. Still, the presented evidence has to be
regarded as preliminary. Future research will have to explore the
presented rational across samples using comparable methodologies.
In summary, decits in verbal intelligence and response
inhibition are long known problems in child and adult impulsive,
antisocial behavior [36,37]. The presented research, from clinically
referred or detained youth samples, suggest that adequate
intellectual capacities, i.e. on the verbal, creative, practical and
analytic realm might be necessary for an individual to behave in a
narcissistic, manipulative, interpersonal style. Furthermore, it
could be suspected that the callous-unemotional and narcissistic
dimensions are less important in relation to poor response
inhibition. There is, thus, rst evidence for differing associations
of intelligence and response inhibition with the different
psychopathy dimensions in children and adolescents with the
most severe behavioral problems.
1.4. Behavior
1.4.1. Aggression
Another aspect of executive functioning, besides intelligence
and response inhibition, is self-control. A lack of self-control is
found in some forms of severe aggression. Severe aggression has
often been documented in children and adults with psychopathic
traits [49,50]. Two forms of aggression have repeatedly been
associated with psychopathic traits [51,52]. Reactive (impulsive)
aggression is unplanned, and driven by heightened emotional
arousal. It occurs in reaction to provocation, frustration or
threatening events. Proactive (instrumental) aggression is planned
and emotionless. It is used to achieve a particular desired goal [53].
On brain level, reactive aggression is often associated with low
frontal lobe functioning and increased amygdala functioning

leading to strong and inappropriately intensive reactions to

threatening and frustrating events. Proactive aggression, a condition particularly associated with psychopathy, has rather been
found to be related to underactive subcortical brain areas,
particularly the amygdala [28,54]. Additionally, a recent molecular
genetic twin study found rst evidence for shared genetic
inuences of psychopathic traits and aggression. This genetic
relation with psychopathic traits was stronger for proactive than
reactive aggression based on child self-report [55]. For an overview
of several correlates of both reactive and proactive aggression, see
Cima and Raine [51].
Different conceptualizations of aggressive behavior exist in the
literature. The reactive-proactive differentiation has been found
appropriate in relation to adult psychopathy and has been
investigated by numerous studies. They generally found higher
total PCL-R/PCL:YV scores in mainly proactive aggressive adult
offenders as well as in relation to a measure of instrumentality and
in relation to both types of aggression in adolescent samples [56
58]. Additionally, in adult offenders the impulsive/antisocial
dimension was associated with poor planning and instrumentality
during aggressive offenses (two factor model; [58]). Recent
evidence indicates that proactive aggression and instrumentality
are specically associated with higher scores on the callousunemotional and narcissistic dimensions, with instrumentality
being associated with the narcissistic dimension only in adult
inmates (four factor model; [2,59]). Thus, the narcissistic dimension
seems to be of special importance in instrumentality and proactive
aggression in adult samples.
Few studies accounted for the differential contributions of the
psychopathy dimensions in relation to the two types of aggression
in child and adolescent samples. Barry et al. [60] applied the APSD
(three factor model), in aggressive children who were assigned to an
intervention program (N = 160, age 912). Interestingly, the
narcissistic dimension predicted high levels of both types of
aggression, whereas the impulsive dimension only predicted
increased reactive aggression. The callous-unemotional dimension
was unrelated to aggression [60]. The authors view the narcissistic
dimension as a unique positive predictor of different types of
aggression in this at risk sample, with higher levels on the
narcissistic dimension being related to higher levels of reactive and
proactive aggression, relative to the other psychopathy dimensions
[60]. This unique relationship between narcissistic, manipulative
behavior and aggression leans some support to the idea that
individuals high on psychopathic traits could use reactive
aggression more consciously than impulsive in a manipulative
way [58,61].
Partly different associations were found applying the APSD
(three factor model) in a clinical child sample (N = 105, age 612;
[62]). Based on caregiver reports, higher levels on the callousunemotional and narcissistic dimensions were both related to
higher reactive and proactive aggression, with slightly stronger
associations for the narcissistic dimension. Higher levels on the
impulsive dimension were exclusively related to higher reactive
aggression. To the contrary, child reports of proactive aggression
were related to higher levels on all three psychopathy dimensions.
Associations with reactive aggression were negative, but nonsignicant [62]. These results suggest that patterns of associations
tend not only to vary between studies, but also across informants.
Two studies in detained youths report on associations between
psychopathy dimensions and the two different aggression types,
applying the PCL:YV. The rst study found high levels on the
narcissistic dimension to be related to increased proactive
aggression (N = 122, age 1217; four factor model). High levels
on the antisocial dimension (added fourth dimension) were related
to less proactive aggression [17]. In the second study by Flight and
Forth [33] proactive aggression was related to higher levels on the

J. Feilhauer, M. Cima / Forensic Science International 224 (2013) 17

callous dimension, whereas reactive aggression was most strongly

related to increased levels on the antisocial dimension (N = 51, age
1620). These authors suggest a distinctive role of CU traits for the
understanding of proactive/instrumental violence ([33]; four factor
model). Callous-unemotional traits are associated with a lack of
empathy and emotions, low levels of autonomic arousal and a lack
of responsibility. According to the authors particularly these
features of psychopathy predispose a psychopathic individual to
act in proactive ways [33,52]. To the contrary, Vitacco et al. [17]
underline the importance of the narcissistic dimension in this
regard. Characteristics as deceitfulness, manipulative behavior, a
grandiose sense of self-worth and impression management might
put psychopathic individuals at risk to become violent when
feeling disrespected or challenged in their position [17,63]. Thus,
the presented results underline the importance of the narcissistic
dimension for proactive aggression. However, they also point to a
substantial role of the callous-unemotional dimension in the
occurrence of both types of aggression in child, adolescent and
adult samples. In summary, proactive aggression seems to be
particularly associated with the callous-unemotional and narcissistic dimensions, representing the psychopathic personality traits
associated with the disorder, and less with the impulsive and
antisocial dimensions, i.e. the behavioral aspects of psychopathy.
At the same time, the presented studies support the almost
exclusive association of the impulsive (and antisocial) dimension
with reactive aggression. These ndings lean indirect support to
the importance of the psychopathic personality traits for the
occurrence of proactive aggression.
1.5. Affect
1.5.1. Cortisol and emotion processing
The hormonal basis of psychopathy is still relatively unknown.
What is known is that psychopaths exhibit low autonomic and
emotional reactivity [61]. On the behavioral level this underarousal seems to be related to their insensitivity to punishment
and fear [64] and their low stress reactivity [61]. Stress reactivity
generally depends on the availability of the stress hormone
cortisol, which is produced by the hypothalamic-pituitary-adrenal
axis (HPA-axis; [65]). Physical and psychological stressors excite
the limbic system, which has an excitatory inuence on the HPAaxis. In psychopaths the limbic system, including the amygdala, is
underresponsive [66]. Cortisol is an important mediator in the
communication between the limbic system and executive cortical
structures; a communication that is believed to be essential for
emotion-processing. Particularly, the decient emotional aspects
of psychopathy are, therefore, believed to be associated with a
reduced cortisol secretion, i.e. underarousal [67,68].
Due to the diminished number of available studies, the
methodological diversity and certain limitations it is still difcult
to determine the precise nature of the association between cortisol
and psychopathic traits. Studies examined the association in highly
deferring samples and varied in whether they examined the tonic
functioning, i.e. basal cortisol levels, the cortisol awakening
response or the stress responsively of the HPA-axis. Furthermore,
cortisol was measured either in blood serum or salivary samples.
Albeit these difculties there is rst evidence linking psychopathy
to low cortisol levels [69]. As a whole, the available literature
points to a critical role of CU traits in the association between
cortisol and psychopathic traits (see [67] for a more detailed
discussion). In support of this hypothesis it has been found that in
children with severe conduct problems, CU traits are similarly
associated with low autonomic activity and a lack of emotional
reactivity to aversive stressors [70].
Two studies explored the relationship between cortisol and the
dimensions of the PCL-R (two factor model). In a longitudinal study

of clinically-referred youths (N = 66124, age 716) with conduct

problems low basal cortisol levels, which are associated with low
autonomic activity, predicted later elevated scores on the callousunemotional/narcissistic dimension [9]. In line with these ndings,
a related study in young adult offenders (N = 20, age 1622),
meeting criteria for the antisocial personality disorder, found low
basal cortisol levels to be related to increased levels on the callousunemotional/narcissistic PCL-R dimension (two factor model [64]).
No correlations were observed with the impulsive and antisocial
dimension. Given the fact that low cortisol has been proposed to be
a biological marker for CU-traits in particular, the contribution of
narcissism is interesting in this context. In sum, ndings from the
literature search suggest reduced cortisol levels, i.e. HPA-axis
hypoactivity, as a biological marker for the callous-unemotional/
narcissistic psychopathy dimension. More research is warranted to
support these preliminary ndings and to further investigate the
role of low cortisol levels in relation to all psychopathy dimensions
and psychopathy related concepts, e.g. the ones discussed in the
present review.

2. Conclusion
Although the literature concerning high-risk samples is still
sparse, it facilitates our insight into the subtle differences in the
relationship between psychopathy dimensions (and aspects of)
cognition, behavior and affect in children and adolescents.
With regard to cognitive ability, increased levels on the
narcissistic dimension seem to be particularly associated with
higher overall and verbal intelligence. A nding that has recently
been replicated in a huge community sample [71]. Interestingly,
through all studies increased levels on the callous-unemotional
dimension were related to lower verbal and overall intelligence.
This nding contradicts earlier ideas in which particularly the
callous-unemotional aspects of psychopathy were thought to be
related to good intelligence [72]. Results support the importance of
unraveling the psychopathy concept into different dimensions.
Regarding response inhibition, there is rst evidence of differential
associations with psychopathy dimensions in detained youth [46].
Furthermore, studies in community samples and studies applying
self-report measures of impulsivity have obtained promising
results, which are in line with the presented rational [47,48].
Across the different samples (detained youth, students, adults
offenders) and studies the callous and narcissistic dimensions
were either unrelated to response inhibition or related to better
inhibition, whereas the impulsive and antisocial dimensions were
related poorer response inhibition. In line with these ndings a
recent review suggests that the long assumed general psychopathy-impulsivity association has to be reconsidered [73]. Different
dimensions of impulsivity might be differently related to
psychopathy. The study of response inhibition as one dimension
of impulsivity might be of special interest in this respect.
The ndings concerning associations of psychopathy dimensions with behavioral aspects give rise to differing interpretations.
Whereas some studies underscore the relevance of the narcissistic
dimension for proactive aggression to occur [17,60], others
attribute this function to the callous-unemotional dimension
[33]. Future research will have to investigate whether both
callousness and narcissism are critical in relation to proactive
aggression. The impulsive and antisocial dimensions, however,
seem to be particularly related to reactive aggression. With respect
to affect, past literature points to low cortisol levels as a unique
biological marker for the callous-unemotional dimension [74].
However, the two studies that took a dimensional approach in
clinical populations indirectly also suggest low cortisol as a
potential marker for narcissism as part of the callous/narcissistic

J. Feilhauer, M. Cima / Forensic Science International 224 (2013) 17

dimension (two factor model; [9,64]). Research will have to clarify

the distinctive role of the narcissistic dimension in this context.
Despite the encouraging overall ndings, the presented
evidence has to be viewed in the light of certain limitations. The
studies presented here applied different operationalizations, i.e.
different dimensional models of psychopathy. We believe that
different factor models can provide useful in research, as different
correlates across dimensions occur. Though, research should aim
at the identication of a general model that adequately covers all
critical domains and proves useful to clinicians in the identication
of differing psychopathic proles and their real life expressions.
The triarchic model of psychopathy as recently proposed by Patrick
et al. suggests a promising alternative that integrates the existing
conceptualizations of psychopathy as well as empirical ndings
[75]. According to the triarchic model, psychopathy can best be
described by three distinct dimensions/phenotypic expressions:
disinhibition, boldness and meanness. Disinhibition generally
captures problems with impulse control; boldness is viewed as the
nexus of high dominance, low anxiousness, and venturesomeness;
meanness reects social and emotional detachment, callousness,
and exploitativeness [75]. According to Patrick [75] the PCL:YV and
APSD index disinhibition and meanness and only to a lesser extant
boldness. The Triarchic Psychopathy Measure (TriPM) systematically covers these three dimensions and presents a promising
framework for guiding and integrating future research on
psychopathy dimensions.
Another difculty concerns the fact that studies utilize
divergent statistical methodologies. Furthermore, studies on
children use different informants, caregiver reports and selfreports, both of which have to deal with certain caveats. Likewise
the amount of instruments and theoretical frameworks applied to
measure cognition, behavior, affect and psychopathy dimensions
makes it difcult to make comparisons and to draw conclusions. In
addition, the partly differing associations between the behavioral
measures and the psychopathy dimensions in children, adolescents and adults illustrate the need for caution in generalizing
ndings over the lifespan. Although the psychopathy dimensions
seem to have considerable construct validity in children and
adolescents, there exist a number of important differences with the
picture seen in adult psychopathy [76]. Given the intense social,
behavioral and biological changes that occur between childhood,
adolescence and adulthood, one should be cautious when talking
about psychopathy in children [7779].
Overall, in line with Frick and others the presented evidence
supports the role of CU traits in the development of psychopathy.
Additionally, it also underscores the importance of the narcissistic
dimension for the understanding of psychopathy in children and
adolescents [60]. The ndings conrm the necessity of the
dimensional approach to psychopathy, and indeed lead one to
assume the existence of different psychopathic proles with
distinct (combinations of) expressions based on a childs position
on each psychopathy dimension. Future research will have to
further illuminate these different proles. Concluding from the
presented literature, we believe that the identication of differing
psychopathic proles might make major contributions to the
design of specic (early) intervention methods based on an
individuals position on each dimension, i.e. dimensional prole.
Given the relative stability of psychopathy [9,80,81] and the
difculties in treating the condition (see [82] for a detailed
discussion), it might, for example, be worth to incorporate the
assessment of psychological well-being in general and psychopathic traits in the standard diagnostic testing during child
development. With early identication children could learn to
regulate narcissistic behavior, including the responses to and
coping with perceived threats, and negative feedback, and could
learn how to earn respect without aggression and antisocial

behavior. Children with CU traits might benet from interventions

that aim at overcoming their affective decits, e.g. by reinstating
their cortisol levels [83]. Higher levels of cortisol are associated
with better communication between cortical and subcortical
structures, i.e. the limbic system. This could lead to a normalized
stress response and an enhanced emotional reactivity could help
the child to achieve the goal of moral socialization [84]. Moreover,
a higher sensitivity of the HPA-axis to environmental cues
reinstates the emotional barrier that usually inhibits proactive
aggression [85]. Also, early therapeutic interventions focused on
the specic dimensions, and a childs dimensional prole, at an
early age seems most promising. Research on psychopathy should
aim at identifying the right starting points for the development of
psychopathy specic, evidence based treatment programs.
References
[1] D.J. Cooke, C. Michie, S. Hart, Facets of clinical psychopathy: toward clearer
measurement, in: C.J. Patrick (Ed.), The Handbook of Psychopathy, Guilford Press,
New York, 2006, pp. 91106.
[2] R.D. Hare, The Psychopathy Checklist-Revised Technical Manual, 2nd ed., MultiHealth Systems, Toronto, 2003.
[3] J.F. Edens, D.K. Marcus, S.O. Lilienfeld, N.G. Poythress Jr., Psychopathic, not
psychopath: taxometric evidence for the dimensional structure of psychopathy,
J. Abnorm. Psychol. 115 (1) (2006) 131144.
[4] J.P. Guay, J. Ruscio, R.A. Knight, R.D. Hare, A taxometric analysis of the latent
structure of psychopathy: evidence for dimensionality, J. Abnorm Psychol. 116 (4)
(2007) 701716.
[5] D.C. Murrie, D.K. Marcus, K.S. Douglas, Z. Lee, R.T. Salekin, G. Vincent, Youth with
psychopathy features are not a discrete class: a taxometric analysis, J. Child
Psychol. Psychiatry 48 (7) (2007) 714723.
[6] J.F. Edens, D.K. Marcus, M.G. Vaughn, Exploring the taxometric status of psychopathy among youthful offenders: is there a juvenile psychopath taxon? Law Hum.
Behav. 35 (1) (2011) 1324, Online publication.
[7] R.E. Christian, P.J. Frick, N.L. Hill, L. Tyler, D.R. Frazer, Psychopathy and conduct
problems in children: II Implications for subtyping children with conduct problems, J. Am. Acad. Child Adolesc. Psychiatry 36 (2) (1997) 233241.
[8] C.T. Barry, P.J. Frick, T.M. DeShazo, M.G. McCoy, M. Ellis, B.R. Loney, The importance of callous-unemotional traits for extending the concept of psychopathy to
children, J. Abnorm Psychol. 109 (2) (2000) 335340.
[9] J.D. Burke, R. Loeber, B.B. Lahey, Adolescent conduct disorder and interpersonal
callousness as predictors of psychopathy in young adults, J. Clin. Child. Adolesc
Psychol. 36 (3) (2007) 334346.
[10] D.M. Blonigen, B.M. Hicks, R.F. Krueger, C.J. Patrick, W.G. Iacono, Psychopathic
personality traits: heritability and genetic overlap with internalizing and externalizing psychopathology, Psychol. Med. 35 (5) (2005) 637648.
[11] H. Larsson, H. Andershed, P. Lichtenstein, A genetic factor explains most of the
variation in the psychopathic personality, J. Abnorm. Psychol. 115 (2) (2006)
221230.
[12] J. Taylor, B.R. Loney, L. Bobadilla, W.G. Iacono, M. McGue, Genetic and environmental inuences on psychopathy trait dimensions in a community sample of
male twins, J. Abnorm. Child Psychol. 31 (6) (2003) 633645.
[13] E. Viding, R.J. Blair, T.E. Moftt, R. Plomin, Evidence for substantial genetic risk for
psychopathy in 7-year-olds, J. Child Psychol. Psychiatry 46 (6) (2005) 592597.
[14] E. Viding, A.P. Jones, P.J. Frick, T.E. Moftt, R. Plomin, Heritability of antisocial
behaviour at 9: do callous-unemotional traits matter? Dev. Sci. 11 (1) (2008)
1722.
[15] P.J. Frick, S.F. White, Research review: the importance of callous-unemotional
traits for developmental models of aggressive and antisocial behavior, J. Child
Psychol. Psychiatry 49 (4) (2008) 359375.
[16] R.T. Salekin, C.S. Neumann, A.M. Leistico, A.A. Zalot, Psychopathy in youth and
intelligence: an investigation of Cleckleys hypothesis, J. Clin. Child Adolesc.
Psychol. 33 (4) (2004) 731742.
[17] M.J. Vitacco, C.S. Neumann, M.F. Caldwell, A.M. Leistico, G.J. Van Rybroek, Testing
factor models of the Psychopathy Checklist: Youth Version and their association
with instrumental aggression, J. Pers. Assess. 87 (1) (2006) 7483.
[18] A.E. Forth, D.S. Kosson, R.D. Hare, Hare Psychopathy Checklist: Youth Version,
Multi-Heath Systems, Toronto, Ontario, 2003.
[19] P.J. Frick, R.D. Hare, The Antisocial Process Screening Device, Multi-Health
Systems, Toronto, Ontario, 2001.
[20] R.D. Hare, The Psychopathy Checklist-Revised, Multi-Health Publishers, Toronto,
Ontario, 1991.
[21] D.J. Cooke, C. Michie, Rening the construct of psychopathy: towards a hierarchical model, Psychol. Assess. 13 (2) (2001) 171188.
[22] C.J. Patrick, M.M. Bradley, P.J. Lang, Emotion in the criminal psychopath: startle
reex modulation, J. Abnorm. Psychol. 102 (1) (1993) 8292.
[23] E. Verona, C.J. Patrick, J.J. Curtin, M.M. Bradley, P.J. Lang, Psychopathy and
physiological response to emotionally evocative sounds, J. Abnorm. Psychol.
113 (1) (2004) 99108.
[24] C.J. Patrick, B.N. Cuthbert, P.J. Lang, Emotion in the criminal psychopath: fear
image processing, J. Abnorm. Psychol. 103 (3) (1994) 523534.

J. Feilhauer, M. Cima / Forensic Science International 224 (2013) 17

[25] J. Blair, D. Michell, K. Blair, The Psychopath: Emotion and the Brain, Blackwell
Publishing, Oxford, UK, 2005.
[26] R.J. Blair, Dysfunctions of medial and lateral orbitofrontal cortex in psychopathy,
Ann. N. Y. Acad. Sci. 1121 (2007) 461479.
[27] E.C. Finger, A.A. Marsh, D.G. Mitchell, M.E. Reid, C. Sims, S. Budhani, et al.,
Abnormal ventromedial prefrontal cortex function in children with psychopathic
traits during reversal learning, Arch. Gen. Psychiatry 65 (5) (2008) 586594.
[28] R.J. Blair, Neuroimaging of psychopathy and antisocial behavior: a targeted
review, Curr. Psychiatry Rep. 12 (1) (2010) 7682.
[29] K.A. Kiehl, A cognitive neuroscience perspective on psychopathy: evidence for
paralimbic system dysfunction, Psychiatry Res. 142 (23) (2006) 107128.
[30] A.R. Hariri, V.S. Mattay, A. Tessitore, B. Kolachana, F. Fera, D. Goldman, et al.,
Serotonin transporter genetic variation and the response of the human amygdala,
Science 297 (5580) (2002) 400403.
[31] L. Pezawas, A. Meyer-Lindenberg, E.M. Drabant, B.A. Verchinski, K.E. Munoz, B.S.
Kolachana, et al., 5-HTTLPR polymorphism impacts human cingulate-amygdala
interactions: a genetic susceptibility mechanism for depression, Nat. Neurosci. 8
(6) (2005) 828834.
[32] P.J. Frick, S.D. Bodin, C.T. Barry, Psychopathic traits and conduct problems in
community and clinic-referred samples of children: further development of the
psychopathy screening device, Psychol. Assess. 12 (4) (2000) 382393.
[33] J.I. Flight, A.E. Forth, Instrumentally violent youths. The roles of psychopathic
traits, empathy, and attachment, Criminal Justice and Behaviour 34 (6) (2007)
739751.
[34] L.C. Munoz, P.J. Frick, The reliability, stability, and predictive utility of the selfreport version of the antisocial process screening device, Scand. J. Psychol. 48 (4)
(2007) 299312.
[35] S.E. Spain, K.S. Douglas, N.G. Poythress, M. Epstein, The relationship between
psychopathic features, violence and treatment outcome: the comparison of three
youth measures of psychopathic features, Behav. Sci. Law 22 (1) (2004)
85102.
[36] A.B. Morgan, S.O. Lilienfeld, A meta-analytic review of the relation between
antisocial behavior and neuropsychological measures of executive function, Clin.
Psychol. Rev. 20 (1) (2000) 113136.
[37] J.T. Nigg, C.L. Huang-Pollock, An early-onset model of the role of executive
functions and intelligence in conduct disorder/delinquency, in: B.B. Lahey, T.E.
Moftt, A. Caspi (Eds.), Causes of Conduct Disorder and Juvenile Delinquency, The
Guilford Press, London/New York, 2003, pp. 227253.
[38] T.E. Moftt, P.A. Silva, Self-reported delinquency, neuropsychological decit, and
history of attention decit disorder, J. Abnorm. Child Psychol. 16 (1988) 553569.
[39] M.J. Vitacco, C.S. Neumann, T. Wodushek, Differential relationships between the
dimensions of psychopathy and intelligence: replication with adult jail inmates,
Crim. Just. Behav. 35 (1) (2008) 4855.
[40] T.E. Moftt, Adolescence-limited and life-course-persistent antisocial behavior: a
developmental taxonomy, Psychol. Rev. 100 (4) (1993) 674701.
[41] M.S. Gazzaniga, R.B. Ivry, G.R. Mangun, Executive functions and frontal lobes, in:
M.S. Gazzaniga, R.B. Ivry, G.R. Mangun (Eds.), Cognitive Neuroscience, 2nd ed.,
Norton & Company, Inc, New York, 2002, pp. 499535.
[42] K.S. Blair, C. Newman, D.G. Mitchell, R.A. Richell, A. Leonard, J. Morton, et al.,
Differentiating among prefrontal substrates in psychopathy: neuropsychological
test ndings, Neuropsychology 20 (2) (2006) 153165.
[43] D. Lapierre, C.M. Braun, S. Hodgins, Ventral frontal decits in psychopathy:
neuropsychological test ndings, Neuropsychologia 33 (2) (1995) 139151.
[44] S. Roussy, J. Toupin, Behavioural inhibition decits in juvenile psychopaths,
Aggress. Behav. 26 (2000) 413424.
[45] S.S. Ishikawa, A. Raine, Prefrontal decits and antisocial behaviour, in: B.B. Lahey,
T. Moftt, A. Caspi (Eds.), Causes of Conduct Disorder and Juvenile Delinquency,
The Guilford Press, London/New York, 2003, pp. 277304.
[46] J. Feilhauer, M. Cima, A. Korebrits, H.J. Kunert, Differential associations between
psychopathy dimensions, types of aggression, and response inhibition, Aggress.
Behav. 37 (2011) 112.
[47] M. Sellbom, E. Verona, Neuropsychological correlates of psychopathic traits in a
non-incarcernated sample, J. Res. Pers. 41 (2007) 276294.
[48] R.J. Snowden, N.S. Gray, Impulsivity and psychopathy: associations between the
Barrett impulsivity scale and the psychopathy checklist revised, Psychiatry Res.
187 (3) (2011) 414417.
[49] I.P. Kruh, P.J. Frick, C.B. Clements, Historical and personality correlates to the
violence patterns of Juveniles tried as adults, Crim. Just. Behav. 32 (1) (2005)
6996.
[50] S. Porter, M. Woodworth, Psychopathy and aggression, in: C.J. Patrick (Ed.),
Handbook of Psychopathy, The Guilford Press, New York, 2006.
[51] M. Cima, A. Raine, Distinct characteristics of psychopathy relate to different
subtypes of aggression, Pers. Individ. Dif. 47 (8) (2009) 835840.
[52] J.R. Meloy, Empirical basis and forensic application of affective and predatory
violence, Aust. N. Z. J. Psychiatry 40 (67) (2006) 539547.
[53] L. Berkowitz, Aggression: Its Causes, Consequences, and Control, Temple University Press, Philadelphia, 1993.
[54] A. Raine, J.R. Meloy, S. Bihrle, J. Stoddard, L. LaCasse, M.S. Buchsbaum, Reduced
prefrontal and increased subcortical brain functioning assessed using positronemission tomography in predatory and affective murderers, Behav. Sci. Law 16
(1998) 319332.

[55] S. Bezdjian, C. Tuvblad, A. Raine, L.A. Baker, The genetic and environmental
covariation among psychopathic personality traits, and reactive and proactive
aggression in childhood, Child Dev. 82 (4) (2011) 12671281.
[56] J.R. Brandt, W.A. Kennedy, C.J. Patrick, J.J. Curtin, Assessment of psychopathy in a
population of incarcerated adolescent offenders, Psychol. Assess. 9 (4) (1997)
429435.
[57] D.G. Cornell, J. Warren, G. Hawk, E. Stafford, G. Oram, D. Pine, Psychopathy in
instrumental and reactive violent offenders, J. Consult. Clin. Psychol. 64 (4) (1996)
783790.
[58] M. Woodworth, S. Porter, In cold blood: characteristics of criminal homicides as a
function of psychopathy, J. Abnorm. Psychol. 111 (3) (2002) 436445.
[59] Z. Walsh, M.T. Swogger, D.S. Kosson, Psychopathy and instrumental violence:
facet level relationships, J. Pers. Disord. 23 (4) (2009) 416424.
[60] T.D. Barry, A. Thompson, C.T. Barry, J.E. Lochman, K. Adler, K. Hill, The importance
of narcissism in predicting proactive and reactive aggression in moderately to
highly aggressive children, Aggress. Behav. 33 (3) (2007) 185197.
[61] L.C. Munoz, P.J. Frick, E.R. Kimonis, K.J. Aucoin, Types of aggression, responsiveness to provocation, and callous-unemotional traits in detained adolescents, J.
Abnorm. Child Psychol. 36 (1) (2008) 1528.
[62] P.J. Fite, L. Stoppelbein, L. Greening, Proactive and reactive aggression in a child
psychiatric inpatient population: relations to psychopathic characteristics, Crim.
Just. Behav. 36 (5) (2009) 481493.
[63] E.M. Cale, S.O. Lilienfeld, Psychopathy factors and risk for aggressive behavior: a
test of the threatened egotism hypothesis, Law Hum. Behav. 30 (1) (2006) 51
74.
[64] M. Holi, L. Auvinen-Lintunen, N. Lindberg, P. Tani, M. Virkkunen, Inverse correlation between severity of psychopathic traits and serum cortisol levels in young
adult violent male offenders, Psychopathology 39 (2) (2006) 102104.
[65] N.A. Nicolson, Hypothalamic-pituitary-adrenocortical hormones, in: L.J. Luecken,
L.C. Gallo (Eds.), Handbook of Physiological Research Methods in Health Psychology, Sage Publications, Thousand Oaks, CA, 2007.
[66] R.J.R. Blair, Subcortical brain systems in psychopathy, in: C.J. Patrick (Ed.),
Handbook of Psychopathy, Guilford Press, New York, NY, 2006, pp. 296312.
[67] D.J. Hawes, J. Brennan, M.R. Dadds, Cortisol, callous-unemotional traits, and
pathways to antisocial behavior, Curr. Opin. Psychiatry 22 (4) (2009) 357362.
[68] E.A. Shirtcliff, M.J. Vitacco, A.R. Graf, A.J. Gostisha, J.L. Merz, C. Zahn-Waxler,
Neurobiology of empathy and callousness: implications for the development of
antisocial behavior, Behav. Sci. Law 27 (2) (2009) 137171.
[69] M. Cima, T. Smeets, M. Jelicic, Self-reported trauma, cortisol levels, and aggression
in psychopathic and non-psychopathic prison inmates, Biol. Psychol. 78 (1)
(2008) 7586.
[70] B.R. Loney, P.J. Frick, C.B. Clements, M.L. Ellis, K. Kerlin, Callous-unemotional
traits, impulsivity, and emotional processing in adolescents with antisocial
behavior problems, J. Clin. Child Adolesc. Psychol. 32 (1) (2003) 6680.
[71] N. Fontaine, E.D. Barker, R.T. Salekin, E. Viding, Dimensions of psychopathy and
their relationships to cognitive functioning in children, J. Clin. Child Adolesc.
Psychol. 37 (3) (2008) 690696.
[72] B.R. Loney, P.J. Frick, M. Ellis, M.G. McCoy, Intelligence, callous-unemotional traits,
and antisocial behaviour, J. Psychopathol. Behav. Assess. 20 (3) (1998) 231247.
[73] N.G. Poythress, J.R. Hall, Psychopathy and impulsivity reconsidered, Aggression
Violent Behav. 16 (2) (2011) 120134.
[74] B.R. Loney, M.A. Butler, E.N. Lima, C.A. Counts, L.A. Eckel, The relation between
salivary cortisol, callous-unemotional traits, and conduct problems in an adolescent non-referred sample, J. Child Psychol. Psychiatry 47 (1) (2006) 3036.
[75] C.J. Patrick, D.C. Fowles, R.F. Krueger, Triarchic conceptualization of psychopathy:
developmental origins of disinhibition, boldness, and meanness, Dev. Psychopathol. 21 (3) (2009) 913938.
[76] R.T. Salekin, J. Rosenbaum, Z. Lee, W.S. Lester, Child and adolescent psychopathy
like a painting by Monet, Youth Violence Juvenile Just. 7 (3) (2009) 239255.
[77] D. Seagrave, T. Grisso, Adolescent development and the measurement of juvenile
psychopathy, Law Hum. Behav. 26 (2) (2002) 219239.
[78] L. Steinberg, The juvenile psychopath: Fads, ctions, and facts, National Institutes of
Justice Perspectives on Crime and Justice: 2001 Lecture Series, vol. 5, 2002, pp.
3564.
[79] L. Steinberg, Cognitive and affective development in adolescence, Trends Cogn.
Sci. 9 (2) (2005) 6974.
[80] P.J. Frick, E.R. Kimonis, D.M. Dandreaux, J.M. Farell, The 4 year stability of
psychopathic traits in non-referred youth, Behav. Sci. Law 21 (6) (2003) 713736.
[81] D.R. Lynam, A. Caspi, T.E. Moftt, R. Loeber, M. Stouthamer-Loeber, Longitudinal
evidence that psychopathy scores in early adolescence predict adult psychopathy,
J. Abnorm. Psychol. 116 (1) (2007) 155165.
[82] R.T. Salekin, C. Worley, R.D. Grimes, Treatment of psychopathy: a review and brief
introduction to the mental model approach for psychopathy, Behav. Sci. Law 28
(2) (2010) 235266.
[83] S.H. Goozen van, G. Fairchild, H. Snoek, G.T. Harold, The evidence for a neurobiological model of childhood antisocial behavior, Psychol. Bull. 133 (1) (2007) 149182.
[84] D.J. Schutter, J. van Honk, Salivary cortisol levels and the coupling of midfrontal
delta-beta oscillations, Int. J. Psychophysiol. 55 (1) (2005) 127129.
[85] J. Haller, M.R. Kruk, Normal and abnormal aggression: human disorders and novel
laboratory models, Neurosci. Biobehav. Rev. 30 (3) (2006) 292303.
[86] H. Cleckley, The mask of sanity, C.V. Mosby, St. Louis, MO, 1941.