Background “With Significant Callous-Unemotional Traits” has been proposed as a specifier for Conduct Disorder (CD) in the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The impact of this specifier on children diagnosed with CD should be considered. Methods A multi-site cross-sectional design with volunteers (n=1136) in the 3rd-7th grades and 566 consecutive referrals (ages 5-18) to a community mental health center were used to estimate the prevalence rates of CD with and without the proposed specifier. In addition, the degree of emotional and behavioral (especially physical aggression) disturbance and level of impairment in youth with and without CD and with and without the specifier was evaluated. Results In the community sample, 10% to 32% of those with CD and 2% to 7% of those without CD met the callous-unemotional (CU) specifier threshold depending on informant. In the clinic-referred sample, 21% to 50% of those with CD and 14% to 32% without CD met the CU specifier threshold depending on informant. Those with CD and the specifier showed higher rates of aggression in both samples and higher rates of cruelty in the clinic-referred sample. Conclusions Results indicate between 10% and 50% of youth with CD would be designated with the proposed CU specifier. Those with CD and the specifier appear to be more severe on a number of indices, including aggression and cruelty.

The current study used model-based cluster analyses to determine if there are two distinct variants of adolescents (ages 11 - 18) high on callous-unemotional (CU) traits that differ on their level of anxiety and history of trauma. The sample (n = 272) consisted of clinic-referred youths who were primarily African-American (90%) and from low income families. Consistent with hypotheses, three clusters emerged, including a group low on CU traits, as well as two groups high on CU traits that differed in their level of anxiety and past trauma. Consistent with past research on incarcerated adults and adolescents, the group high on anxiety (i.e., secondary variant) was more likely to have histories of abuse and had higher levels of impulsivity, externalizing behaviors, aggression, and behavioral activation. In contrast, the group low on anxiety (i.e., primary variant) scored lower on a measure of behavioral inhibition. On measures of impulsivity and externalizing behavior, the higher scores for the secondary cluster only were found for self-report measures, not on parent-report measures. Youths in the primary cluster also were perceived as less credible reporters than youth in the secondary or cluster low on CU traits. These reporter and credibility differences suggest that adolescents within the primary variant may underreport their level of behavioral disturbance, which has important assessment implications.

This article outlines a provisional evidence-based approach to the assessment of pediatric bipolar disorder (PBD). Public attention to PBD and the rate of diagnosis have both increased substantially in the past decade. Accurate diagnosis is crucial to avoid harm due to mislabeling or unnecessary medication exposure. Because there are no proven efficacious or effective treatments for PBD, the role of assessment is heightened to demonstrate efficacy in individual cases as well as to identify cases for participation in clinical trials. This review discusses (a) the state of psychopathology research regarding PBD; (b) the likely base rate of PBD in multiple clinical settings; (c) the diagnostic value of family history; (d) challenges to differential diagnosis, including comorbidity and symptom overlap with other diagnoses, shortcomings in contemporary assessment methods, and the cyclical nature of PBD; (e) practical methods for improving diagnosis, focusing on the most discriminative symptoms, extending the temporal window of assessment to capture mood changes, and using screening tools within an actuarial framework; and (f) monitoring response to treatment using a variety of assessment methods. Twelve recommendations are offered to move toward an evidence-based assessment model for PBD.

Evidence-based assessment (EBA) streamlines literature reviewing and organizing clinical assessment by targeting the vital few topics, "satisficing," and focusing on three major phases of clinical activity: prediction of diagnoses or other criteria, prescription of treatment or moderating factors, and process measurement. EBA is an organizing framework for applying a dozen steps to guide treatment. Technology is changing clinical assessment by increasing the efficiency and accuracy of scoring and feedback, as well as innovations that make more intensive assessment feasible. Fully implementing EBA suggests changes in training and requires a practice overhaul in exchange for greater efficiency, more accurate decisions, incrementally better outcomes, and increased service accessibility that could enable psychological science to help more people.

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