Conduct disorder affects around 2–2.5% of children and adolescents worldwide (Fairchild et al., 2019). It is associated with marked impairment, including persistent antisocial behaviour, substance misuse, educational difficulties, and peer and family conflict, and can lead to long-term social and economic burden (GBD 2019 Mental Disorders Collaborators, 2022; Fairchild et al., 2019). Yet despite its impact, conduct disorder is far from a uniform condition, with individuals sharing the same diagnosis often differing in symptom severity, comorbidity, and treatment response (Fairchild et al., 2019; Fanti, 2018).
This raises an important question: are there meaningful subgroups within conduct disorder that help explain this variation?
One attempt to better characterise it was the introduction of the DSM-5 limited prosocial emotions specifier, which identifies a subtype of conduct disorder. The specifier is based on callous-unemotional traits, which typically involve low empathy, little guilt or remorse, limited concern about performance, and shallow emotional expression (American Psychiatric Association, 2013).
However, more than a decade after its introduction, it remains unclear whether the specifier reliably distinguishes a clinically meaningful subgroup. This may partly reflect how limited prosocial emotions have been assessed, with many studies relying on brief questionnaire measures that do not fully capture the DSM-5 criteria or the complexity of callous-unemotional traits (Colins et al., 2020; Frick et al., 2014).
In this context, Colins and colleagues (2026) attempted to address these limitations by using a clinician-rated assessment, the Clinical Assessment of Prosocial Emotions (Frick, 2013), alongside a wide range of relevant measures in a forensic sample of adolescents.
Methods
The sample comprised 323 boys aged 16–17 years from two Flemish youth detention centres in Belgium. Participants took part in three assessment sessions, including:
- Structured diagnostic interviews to assess conduct disorder diagnosis, symptom profiles, and whether the young person met criteria for limited prosocial emotions
- Self-report questionnaires to measure a range of emotional and behavioural difficulties, alongside empathy, boldness, parenting experiences, treatment engagement, peer relationships, and school experiences
- Computerised tasks to assess delay discounting, behavioural risk taking, response inhibition, and emotion recognition
Based on the diagnostic interviews, participants were separated into three groups: conduct disorder alone (n = 115), conduct disorder with limited prosocial emotions (n = 173), and neither (n = 32). Three additional participants met criteria for limited prosocial emotions without conduct disorder, but this group was too small to include in the analyses.
Notably, around 60% of adolescents with conduct disorder also met criteria for limited prosocial emotions. This is important because the specifier is intended to help identify a subgroup within conduct disorder, yet in this detained sample it applied to the majority of those with the diagnosis.
Chi-squared tests and one-way analysis of variance were used to compare the measured characteristics across the three groups. The researchers then focused on participants with conduct disorder and used regression analyses to test whether limited prosocial emotions were associated with these characteristics beyond conduct disorder severity and attention-deficit/hyperactivity disorder (ADHD) features.
Results
Adolescents with both conduct disorder and limited prosocial emotions showed a more severe clinical profile than the other two groups. Compared with those who had conduct disorder alone and those with neither, they showed:
- Markedly greater conduct disorder severity, including higher levels of aggression and deceitful or theft-related behaviours;
- Elevated reactive and proactive aggression and more pronounced oppositional defiant features.
Their difficulties extended beyond conduct problems. They were more likely to have experienced multiple school expulsions and were less engaged with treatment.
This group also showed a distinct profile of individual and environmental characteristics. Compared with the other two groups, they reported:
- Higher levels of boldness and lower levels of both affective and cognitive empathy, meaning that they tended to be more socially fearless and less able to understand or respond to others’ feelings;
- Greater delay discounting, indicating a tendency to favour immediate rewards over waiting for larger future gains.
In terms of environmental context, this group showed a more adverse social backdrop, experiencing greater exposure to peers with a history of incarceration. Initially, they also reported less warm maternal parenting, but these differences were no longer significant once conduct disorder symptom severity was controlled for.
Not all characteristics showed group differences. There were also no clear differences between the groups in anxiety or depression, risk-taking, response inhibition and several other characteristics. Notably, adolescents with limited prosocial emotions were no more likely to have childhood-onset conduct disorder than those with conduct disorder alone.
Importantly, most of the identified differences remained even after taking conduct disorder severity and ADHD features into account. For 11 of the 15 characteristics that distinguished the two conduct disorder groups, associations with limited prosocial emotions remained statistically significant after adjusting for conduct disorder severity, childhood-onset conduct disorder and ADHD features.
Conclusion
The authors conclude that these “findings provide important and novel evidence to support the utility of the DSM-5 [limited prosocial emotions] specifier for [conduct disorder]”.
Across the three groups, adolescents differed in clinical, cognitive, emotional, and environmental characteristics, extending beyond their conduct disorder symptoms to a broader range of individual and environmental characteristics. Notably, many of these differences remained even after taking conduct disorder severity and ADHD features into account, suggesting that the specifier may contribute to a better understanding of the variation within conduct disorder that cannot be explained simply by how severe an individual’s symptoms are. However, around 60% of adolescents with conduct disorder met criteria for limited prosocial emotions in this sample, raising questions about how clearly the specifier delineates a distinct subgroup.
Strengths and limitations
Several aspects of the study design stand out as clear strengths:
- Unlike most earlier research, which relied on questionnaires that were not designed around the DSM-5’s specific criteria, this study used the Clinical Assessment of Prosocial Emotions. It is an expert-rated tool developed specifically to assess the DSM-5 specifier more comprehensively.
- The researchers used multiple methods to examine a broad range of clinically, etiologically, and other relevant characteristics. This allowed them to better characterise the subgroup and improve our understanding of the specifier, contributing to the sparse evidence-base.
- Participants were recruited from the juvenile justice system, where a large number of adolescents may already present with conduct problems. This provides an important research setting in which the specifier may be particularly informative (Kahn et al., 2012).
However, no study is perfect, and there are several limitations that must be considered, including:
- The cross-sectional design means the findings indicate associations rather than causal relationships, highlighting the need for longitudinal research.
- Although this clinician-rated tool is designed to draw on multiple informants, the study did not include reports from parents, teachers or other significant adults. Ratings were primarily based on interviews with the adolescents, supplemented by information from detention-centre files. This may be important because the DSM-5 recommends considering information from multiple sources.
- The sample was restricted to male adolescents in juvenile detention centres in Belgium, limiting generalisability to females, community samples, and other cultural contexts. Evidence suggests that there are gender differences in the developmental pathways of childhood conduct problems (Gutman et al., 2018), meaning that a single-gender sample may not capture the full picture.
- Only three participants met criteria for limited prosocial emotions without conduct disorder, meaning the researchers could not meaningfully examine this group on its own. This makes it difficult to determine whether some of the observed characteristics are associated with limited prosocial emotions independently of conduct disorder.
- The study did not compare this clinician-rated assessment directly with shorter questionnaire measures of callous-unemotional traits, so it remains unclear whether its more comprehensive and time-consuming assessment provides enough additional information to justify its use in practice.
Implications for practice
Taken together, these findings add to growing evidence for the potential utility of the DSM-5 specifier for identifying elevated callous-unemotional traits among adolescents with conduct disorder (Frick et al., 2013, 2014).
From a clinical perspective, the DSM-5 limited prosocial emotions specifier may offer a useful way of thinking about the variation within conduct disorder. The findings suggest that it may reflect more than simply greater symptom severity, and instead capture a broader profile of associated characteristics. Specifically, it could support the recognition of a subgroup of adolescents who differ not only in clinical presentation, but also in the pattern of associated individual and environmental characteristics. This is particularly relevant given the lower treatment engagement and more frequent school exclusion observed in this group, which may point towards the need for more tailored interventions. Home-based treatment, for example, may lead to greater access to resources (read Akansha Naraindas’s Mental Elf blog to learn more).
At the same time, the differences we see in peer experiences hint at something broader. These difficulties don’t seem to sit neatly within the individual alone; instead, they may be embedded within a wider social environment. This raises the possibility that focusing solely on individual clinical symptoms may overlook important contextual influences that shape developmental processes in this subgroup. Although this study did not test interventions, the findings highlight the potential importance of considering family, school and peer contexts alongside individual clinical characteristics. Whether interventions targeting these contexts improve outcomes specifically for adolescents with conduct disorder and limited prosocial emotions remains to be tested.
However, the Clinical Assessment of Prosocial Emotions is still relatively understudied, and more research is needed to establish its practical usefulness in real-world settings, including whether its more comprehensive assessment provides meaningful benefits over shorter measures of callous-unemotional traits. Future studies should also incorporate information from caregivers, teachers or other significant adults alongside adolescents’ own reports. Also, as has been pointed out by the authors, the observed group differences were generally small to moderate in size, suggesting that while patterns exist, they should not be over-interpreted. This is important when considering potential clinical or judicial applications, where there is a risk of over-reliance on group-level findings when making individual decisions (Grove, 2005).
Statement of interests
Junming Wei has no conflicting interests to declare.
Edited by
Dr Nina Higson-Sweeney
Links
Primary paper
Oliver F. Colins, Thomas Cassart, Emmely Delamillieure, Kostas A. Fanti, Melina Nicole Kyranides, Maria Sikki, Maria Petridou, & Paul H. F. Meens (2026). Conduct disorder with limited prosocial emotions: a multimethod study in criminal justice‐involved boys. Journal of Child Psychology and Psychiatry, 67(7), 1062-1072. https://doi.org/10.1111/jcpp.70118
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