The influence of Callous Unemotional traits on heart rate
in girls with conduct disorder during the Trier Social
Stress Test.
Masterthesis
Maxime van Velzen
Tutor: Dr. Evelyn Heynen
Healthcare Psychology
Master track Clinical Forensic Psychology
Faculty of Social- and Behavioral Sciences
University of Amsterdam
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Preface
In September 2016, the adventure called studying Clinical Forensic Psychology at the University of Amsterdam began. This master consisted of two months of intensive theoretical education, followed by two internships: a clinical internship and an academic internship. My clinical internship will take place at the penitentiary institution in Alphen aan den Rijn. My academic internship took place at the FemNAT-CD study “Neurobiology and Treatment of Female Adolescent Conduct Disorder: The Central Role of Emotion Processing” at the Academic Medical Center Amsterdam (AMC) and the VU Medical Center at Amsterdam (VUmc). This study researches conduct disorder in girls in the age range nine until eighteen years old. The FemNAT-CD study is not only active in the Netherlands, it is an European study, conducted in the UK, Germany, Ireland, Switzerland, Spain, Greece and Hungary1.
During my academic internship, I learned a lot about conducting a study in a big population. At first, I was responsible for including and testing girls in the control group. After, I was responsible for including and testing girls in the case group. Both administrative tasks and clinical tasks were part of my responsibility. The Trier Social Stress Test (TSST) – one of the tests within the test battery of this study – got my attention and I decided to use the data for my thesis. This is why I managed to lead several TSST’s during my internship.
I am very thankful that I gained this much clinical- and practical knowledge and skills during this internship. All of this knowledge will help me during my clinical internship at Alphen aan den Rijn.
A special thanks to Helena Oldenhof, Arthur van Rhijn and Lisette van den Boogaard for assisting me during my internship and the process in which I wrote my masterthesis. I also want to thank my tutor at the University of Amsterdam, Evelyn Heynen, for the feedback, flexibility and meetings (in person or via Skype). Thank you!
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Abstract
This study investigated whether girls who have Conduct Disorder (CD) and meet the Callous- and Unemotional Specifier (CU specifier) had a lower basal heart rate in beats per minute (bpm) during the Trier Social Stress Test (TSST) than did girls who have CD but did not meet the CU specifier. It was expected that the nine girls who met the CU specifier had a lower basal heart rate in general and during the TSST than did the eleven girls who did not meet the CU specifier. It was also expected that girls who did meet the CU specifier had a faster heart rate recovery than did girls who did not meet the CU specifier.
The TSST activates stress in her participants, in order to test psychological-, physiological- and neurobiological responses to stress. The heart beat in bpm was measured throughout the TSST, and this study used the average basal heart rate data during three timeslots of the TSST. The timeslots were: ten minutes pre stress-task standing, ten minutes stress-task and ten minutes post stress-task standing. Statistical analyses showed interesting results, concerning basal heart beat in bpm and heart rate recovery. Girls with CD who met the CU specifier did have a lower basal heart rate throughout the TSST than did girls with CD who did not meet the CU specifier. The differences in heart rate in bpm between the two groups were not significant when it came to the three timeslots. In other words: girls with CD who did meet the CU specifier did not have a significantly lower heart rate from timeslot one to timeslot two, and from timeslot two to timeslot three than did girls with CD who did not meet the CU specifier. The heart rate recovery of girls with CD who did meet the CU specifier was not significantly faster than the heart rate recovery of girls with CD who did not meet the CU specifier, but the results did go in the expected direction.
This study aimed to slowly fill a gap in research containing female CD. It showed that female CD is different from male CD, which makes it more important to investigate female CD in more detail, in order to help females who suffer from CD in daily life and therapy.
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Introduction
Behavioral problems based on aggression and criminal behavior among adolescents are a growing social problem (Heynen e.a., 2016). Associated costs for the society are enormous and continuous (Scott, Knapp, Henderson & Maughan, 2001). Adolescents who show these forms of aggression and criminal behavior often suffer from conduct disorder (CD) (APA, 2013). CD is often characterized as a persistent- and repetitive pattern of behavior in which the basic rights of others and/or societal norms are violated (Moffitt e.a., 2008). Adolescents with CD often have trouble dealing with authorities and they often take part in arguments and/or fights. Other features of CD include impairment in social, academic and/or professional functioning (APA, 2013; Moffitt e.a., 2008).
In DSM-V, the so-called “Callous- and Unemotional Specifier” (CU specifier) is added as a subtype of CD (Moffitt e.a., 2008; APA, 2013). According to Frick and White (2008), the group of adolescents diagnosed with CD can be divided into two different groups: adolescents with CD who do not meet the CU specifier and adolescents with CD who do meet the CU specifier. CU traits are multidimensional and consist of several factors (e.g. cognitive, affective and behavioral factors). For example, Edens, Skeem, Cruise and Cauffman (2001) argue that CU traits consists of behavior characterized by impulsiveness, sensation seeking and aggression. The presence of CU traits can be assessed by investigating if the person is lacking remorse, lacking empathy, has superficial affect and/or is unconcerned about performances in daily life (Colins & Vermeiren, 2013). Adolescents who meet the CU specifier do not respond well on treatment and have an increased risk to develop antisocial behavior in adulthood (Frick & White, 2008; Fontaine, McCrory, Boivin, Moffitt & Viding, 2011). Or more extreme, they have an increased risk to develop psychopathy in adulthood (Das, 2008; Das, de Ruiter, van Heteren & Doreleijers, 2004). Psychopathy in adulthood causes more criminality, bad family ties and addiction (Lammers et.al., 2014).
The study of Murray (2010) states that in 6 up to 16 percent of adolescent boys, CD is present. In 2 up to 9 percent of girls ODD is present. Other studies also show a significant higher prevalence of CD among boys than among girls (Dretzke e.a., 2005; Maughan e.a., 2004). Earlier studies point out that boys who meet the CU specifier are more aggressive, impulsive, rebellious and superficial in affect than boys who do not meet the CU specifier (Frick & White, 2008; Edens, Skeem, Cruise & Cauffman, 2001; McCrory, Boivin, Moffitt & Viding, 2011). Boys who meet the CU specifier often want to achieve a
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goal with their aggression (proactive aggression) and they have poor impulse control (Berkout, 2011). Comorbidity of male CD (and CU specifier CD) most often contains ADHD or ADD (Berkout, 2011; Edens, Skeem, Cruise & Cauffman, 2001). Male CD can be associated with low levels of anxiety and depression (Pardini e.a., 2012; Frick & White, 2008).
Male CD and males who meet the CU specifier were examined in more detail in previous research than are females with CD and females who meet the CU specifier. Findings in previous studies about CD/CU specifier suggest that males and females cannot be treated and thought of as identical: they differ in several characteristics and therefore need different approaches (Dretzke e.a., 2005).
Comorbidity of CD in girls is also different from comorbidity of CD in boys: CD in girls is comorbid with depression and with anxiety (Bardone, 1998; Costello e.a., 2003). Nevertheless, females diagnosed with CD have more anxiety problems and show fewer externalizing disorder symptoms than males diagnosed with CD. Girls who meet the CU specifier often show reactive aggression (being aggressive as a reaction to actions of others; e.q. kicking or slapping someone in a discussion) or relational aggression (knowingly exclude people or knowingly ruin friend- or relationships of others) (Marsee, Silverthorn & Frick, 2005; Marsee & Frick, 2007; Pardini e.a., 2012).
As stated earlier, CD in girls is more persistent than in boys (Costello e.a., 2003) and develops at a young age, resulting in trouble with integration in (working) life, health problems and/or involvement in (teenage) prostitution (Bardone, 1998; Herpertz-Dahlmann, 2014). These factors influence not only the behavior of the CU specifier girls, but also the relationships they have with their parents (and/or caregivers), friends, family and themselves (Bardone, 1998). Those relationships often are (very) stressful, which means girls with CD/CU must cope with relatively high levels of stress (Delligatti, Akin-Little & Akin-Little, 2003).
Van Goozen et. al. (1998) showed that stress has an influence on (the symptoms of) CD. People with CD do have a lower heart rate during rest and stress, but individual differences were large: when anxiety was experienced, participants felt more aggressive and showed more externalizing behavior during stress. According to Berkout, Young and Gross (2011), there is strong evidence for a differential etiology and neurobiology of female CD.
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One way to get insight in the earlier mentioned neurobiological differences is measuring the influence of stress on an individual. According to de Vries-Bouw et. al. (2011), reactions of autonomic responses may have predictive values for antisocial behavior. More specifically: low autonomic activity and/or reactivity are consistent correlates of antisocial behavior in adolescents.
According to Collins & Frankenhaeuser (2010), the central nervous system (CNS) of boys does differ from the CNS of girls. The CNS in girls does have their own nervous tracts and the female CNS therefore responds differently to stress (Collins & Frankenhaeuser, 2010). Their parasympathic nervous system consists of mostly nerve cells that respond to neurotransmitters like acetylcholine. An important nerve is the nerve vagus, which is connected to the heart and controls the slower heartbeats when the person is in rest. The nerve sympaticus is also connected to the heart and controls the quicker heartbeats when the person has the flight response (MacLusky & Naftolin, 1981). One indicator of autonomic activity is heart rate. Heart rate indicates activity in the sympathetic- and parasympathetic nervous systems (SNS and PNS) in the human body. These nervous systems have opposing actions on organs: the SNS prepares the organism for fight- of flight actions (increasing heart rate), whereas the PNS is involved in activities that require slower heart rate and lower emotional arousal (decreasing heart rate) (Banyard, Davies, Norman & Winder, 2010; Pinel, 2015). Indication of activity in both SNS and PNS can be found in heart rate variability (HRV). According to Beauchaine (2001 in: de Vries-Bouw e.a., 2011 p. 1598), heart rate variability is “the variation in the interval between consecutive heart beats in the respiration frequency range due to the influence of the vagus nerve on the sinoatrial node.”
The interest in these sorts of neurobiological markers in criminal youth has increased. This made the influence of the human stress-regulating systems – such as the autonomic nervous system (ANS) – more prominent in research regarding CD and criminal behavior. According to de Vries-Bouw et. al. (2011), the low arousal theory (Zuckerman, 1979 in: de Vries-Bouw e.a., 2011) can cause this predictive value of low heart rate in people who show delinquent behavior. To optimize their unpleasant physiological state (low arousal), people start to display antisocial and/or delinquent behavior: their sensation seeking is higher. Arnett (1997) examined insensitivity to punishment in psychopaths. According to Fowles (1980, in: Arnett, 1997), people with high scores on psychopathy show slower heart rate increase during a fearful event than
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do control subjects. Heart rate is a measurement of the ANS. Autonomic responses via the ANS are important for regulation of unconscious functions, like regulation of internal organs (e.g. digestion, heart rate and breathing) (Sztajzel, 2004).
Anastassiou-Hadjicharalambous and Warden (2008) examined both verbal and autonomic responses to a fearful event presented on video in children with CD. One of the autonomic responses these authors examined was heart rate. Children high in CU traits showed less heart rate change than children low in CU traits.
Several studies indicated reduced baseline PNS activity in criminal youth (Beauchaine, Hong & Marsch, 2008; de Vries-Bouw e.a., 2011). Research on heart rate during stress is scarce, but according to Ortiz and Raine (2004) a strong effect size can be found for low heart rate during a stressor in relation to antisocial behavior. Their meta-analysis showed that low resting heart rate can be a consistent biological correlate of antisocial behavior in youth. Previous studies on low resting heart rate showed that the predictive value of low resting heart rate in three-year-old boys for future aggressive behavior was strong (Raine, Venables & Mednick, 1997 in: de Vries-Bouw e.a., 2011). In a male adolescent sample, low resting heart rate at age 15 was related to criminal behavior at age 24 (Raine, Venables & Williams, 1990 in: de Vries-Bouw, 2011). Even though the influence of biological markers and autonomic responses in criminal youth is proven, most studies examine heart rate in rest – not during stress – as a predictor of antisocial behavior in youth.
According to Venables (1987, in: Arnett, 1997), theory is suggesting that inadequate autonomic responses are responsible for the lack of affect and empathy in psychopaths. It is important to state that psychopaths and boys with CD do not have the exact same profile, but the profiles of both the psychopaths and the boys with CD depend on antisocial behavior (Frick & White, 2008).
The study of Beauchaine and Hong (2008) also examined autonomic responsivity in CD youth and states that CD boys do show reduced autonomic functioning compared to non-CD boys. Because their autonomic functioning is reduced, CD boys show more aggressive behavior and they do not fear the consequences of antisocial behavior. The finding of de Vries-Bouw et. al. (2011) supports this by stating that, in boys with CD, co inhibition is found. This means: weakend heart rate reactivity and increased vagal withdrawal of the heart at the same time. These low levels of PNS stand in line with antisocial- and/or criminal behavior in youth (de Vries-Bouw e.a., 2011; Beauchaine &
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Hong, 2008). De Vries-Bouw et. al. (2011) validate the assumption that disturbed ANS activity and reactivity contribute in delinquent behavior. According to Shetler et. al. (2001), heart rate recovery is mediated by vagal reactivation. Since male CD is characterized by weakened heart rate reactivity and increased vagal withdrawal, recovery of heart rate will take less time in people who meet the CU specifier than in people who do not meet the CU specifier.
Female CD/CU is being a highly neglected research area, which causes a significant gap of knowledge. This is causing a lack of neuropsychological and neurobiological mechanism-based treatment approaches (Scott e.a., 2011; Herpertz-Dahlmann, 2014). In order to broaden the knowledge about female CD and improve treatment of females with CD, this study focusses on girls with CD. This study aims to gain more insight in heart rate variability in girls with CD during stress. Both girls who do meet the CU specifier and girls who do not meet the CU specifier will be taken into account. In order to answer this question, three hypotheses will be investigated: (H1) “Girls who meet the CU specifier do have a generally lower basal heart rate than girls who do not meet the CU specifier.” (H2) “The reactivity of girls who meet the CU specifier is lower than the reactivity of girls who do not meet the CU specifier.” And (H3) “Girls who meet the CU specifier have a faster heart rate recovery after performing a stress task than do girl who do not meet the CU specifier”.
Method
Sample
The FemNAT-CD study is a cross sectional cohort study that concentrates on girls with conduct disorder. The study is carried out in different countries in Europe (including the UK, Germany, Ireland, Switzerland, the Netherlands, Spain, Greece and Hungary). Data obtained in the Netherlands is used in this article. This study distinguishes two groups: girls who do meet the CU specifier (CU + group), and girls who do not meet the CU specifier (CU - group). The used data is obtained from girls in different residential health care institutions in the Netherlands2. The analyzed population in this article is a case sample
of 20 girls in the age of 9 up to 18 years old (mean= 14.60, SD=1.80). The girls aged 9 up to 12 (N=3) are diagnosed with oppositional defiant disorder (ODD) and at least one
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criteria of CD, the girls aged 13 years and up (N=17) are diagnosed with ODD and at least two criteria of CD.
Participants were excluded from the study when they met criteria for schizophrenia or autism spectrum disorder, a current clinical diagnosis of bipolar disorder or mania. Other exclusion criteria were a diagnosis of monogenetic disorder, a genetic syndrome (e.g. fragile-X-syndrome, down’s syndrome, Prader-Willi-syndrome, metabolic disorder) and having any chronic or acute neurological disorder (e.g. cerebral palsy, current treatment for epilepsy, history of moderate- to severe traumatic brain injury). The final exclusion criteria was an IQ below 70.
Consent
The FemNAT-CD study has been approved by the METC VUmc and is registered under 2014.18. Participants and their legal guardians were informed about the study, after which there was a period of at least 24 hours in which they could consider participation. Participants and their legal guardians gave written informed consent prior to participation. Participation of the FemNAT-CD study was voluntary and anonymous. Procedure
The results of this study were based on data retrieved by completion of the Trier Social Stress Test (TSST), a widely used task for inducing (lab-based) stress in adolescents and adults (Buske-Kirschbaum e.a., 1997 in: McLauglin, Alves & Sheridans, 2013). The TSST was performed between 1pm and 6pm, and took two hours and 15 minutes (figure 1).
In the first hour of data collection, the participants were free to relax. This meant (e.g.): polishing nails or reading a magazine. After 50 minutes of relaxation, the participants were asked to stand for ten minutes. Afterwards, the participants were asked to follow the test leader to another room. Here, three discrete periods involving TSST took place: the participants were asked to prepare and deliver a speech and perform a mental subtraction test, both in front of a two-faced jury with a camera.
The first discrete period involving TSST was the preparation of the speech, which the participants had to deliver in front of the jury (McLauglin, Alves & Sheridans, 2013). The participants were asked to deliver a speech about a movie they saw. The participants got three minutes to prepare this speech. After this preparation, the jury entered the room, pretending to activate the camera (this was only done to create more stress in
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participants, the camera was not really switched on). After the entrance of the jury in the room, the participant was asked to start their five-minute speech (second discrete period). After the speech, the participant was asked to perform a mental subtraction task (third discrete period). During this task, the participant was asked to count back in steps of seven. The jury asked the participant to start all over when the participant gave a wrong answer. The jury was trained and instructed to give negative- up to neutral feedback.
In the final hour of data collection, the participants were able to relax again. The first ten minutes had to be done standing. The test leader told the participant that their speech was not filmed and that the task was only done in order to induce stress levels. Positive feedback about the speech and mental subtraction task was also given in this stadium of the data collection period. During the entire data collection, the participants were connected to the VU-AMS in order to measure heart rate, respiratory sinus arrhythmia and respiration rate throughout all three periods of the TSST (Houtveen, de Groot & De Geus, 2005).
Figure 1. Schematic representation of the TSST.
Dependent variables
Physiological measures
The VU-AMS provided cardiac data on ANS activity. Heart rate, respiratory sinus arrhythmia and respiration rate were recorded throughout the TSST (Houtveen, de Groot & De Geus, 2005). Electrocardiogram (ECG) recordings and cardiac impedance recordings
Deconnection of VU-AMS
Participant gets deconnected from VU-AMS
Relaxation #2
Participant is asked to stand for 10 minutes (post task standing) Participant is able to relax for 50 minutes
Mental subtraction task
Participant is instructed about the mental subtraction task Participant performs mental subtraction task
Speech
Participant performs five minute speech in front of the jury
Speech preparation
Participant gets assignment to perform a speech in front of a jury Participant prepares the speech in 3 minutes
Relaxation #1
Participant is able to relax for 50 minutes After 50 minutes, the participant is asked to stand for 10 minutes (pre task standing)
Connection to VU-AMS
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were obtained by the use of the VU-AMS in order to measure heart-rate in beats per minute (bpm).
For the measurement of ECG R-peak to R-peak intervals, three electrodes were used: one below the right collar bone (four centimeters off the sternum), one between the lower two right ribs and one four centimeters under the left nipple, under the breast. For the measurement of thoracic impedance, four electrodes were used: two electrodes were placed on the torso, of which one at the top end of the sternum and the other one at the low end of the sternum. The other two electrodes were placed on the back of the spine: one electrode at the base of the neck (vertebrae C4/C4) and the other electrode was placed three centimeters below the lowest electrode on the torso.
Scoring of this data was done by using the software program DAMS 3.9. Scoring this data consisted of visual inspection- and manual correction of the R-peaks; clipping of artefacts (PVC, PAC and bad ECG signals), scoring of the QRS-complex, T-wave and T-offset positions in the ECG and inspection of the clipped respiration data. Heart rate reactivity was calculated by subtracting the average baseline heart frequency from heart frequency during stress. The difference between the longest and the shortest R-wave to R-wave interval was used as an index of RSA (RSA was set as missing data when the irregular respiration was more than 50%).
Independent variables
Measurement of CU-traits
In order to measure the independent variable ‘CU traits’, the Youth Psychopathy Inventory (YPI) was used (appendix 1). All the girls completed this questionnaire during the FemNAT-CD study. The YPI is a self-report measurement tool for detection of psychopathy (CU traits) in adolescents (Andershed, Hodgins & Tengström, 2007). The questionnaire consists of 50 items that are testing the three-factor model of psychopathy (Cooke & Micie, 2001; in: Colins & Vermeiren, 2013). According to Colins and Vermeiren (2013), there can be an distinction between adolescents who meet the CU specifier and adolescent who do not meet the CU specifier. This distinction can be made by focusing on three subscales, the so-called CU subscales (Colins & Vermeiren, 2013): remorselessness (items 8, 21, 28, 44, 48), callousness (items 12, 17, 23, 35, 49) and unemotionality (items 2, 25, 36, 39, 45).
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Adolescents are assigned to the CU+ group when they rate one of the items on at least two subscales a ‘4’ (“applies very well”). The population of this study (N=20) is divided in two groups using this rule: the CU specifier group (N=9) and the CU - specifier group (N=11). An example of an item in the remorselessness subscale is “To feel guilty and remorseful about things you have done that have hurt other people is a sign of weakness.” Adolescents were able to rate the following statement in the callousness subscale: “I think that crying is a sign of weakness, even if no one sees you.” And the unemotionality subscale consisted of items such as: “I usually feel calm when other people are scared.”
According to Andershed, Hodgins and Tengström (2007), the convergent validity of the YPI is good. This means that in several studies (who are somewhat alike), the YPI did give the same outcomes. The area under the ROC curve of the YPI is .68, which makes the YPI a valid and useable tool to measure CU traits in the population of this study (Andershed, Hodgins & Tengström, 2007).
Statistical analysis
To test the first hypothesis, a mixed ANOVA was used. For the second- and third hypothesis, an one sample T-test and a 2x2 ANOVA were executed. The dependent variables used in the statistical analyses were heart rate (in bpm) in the three timeslots. The independent variable used in the statistical analyses was the separation of the CU+ and CU- groups. In the statistical analyses for the second hypothesis, timeslot one and timeslot two were used. In the statistical analyses for the third hypothesis, timeslot two and three were used.
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Results
Descriptive statistics and correlations
Table 1 represents the correlations between the CU+ group, the CU- group and the three timeslots. The correlation between pre task standing and the speech task was – as expected - significant (r=0.84, p<0.001). The correlation between pre task standing and post task standing was also – as expected – significant (r=0.96, p<0.001). Another significant correlation was the correlation between speech task and post task standing (r=0.90, p<0.001). This positive correlation was also expected.
Table 1.
Means, Standard Deviations (SD) and correlations between the independent variable and the dependent variables pre task standing, speech task and post task standing.
Correlation
Mean (SD) Group Pre task standing Speech task Post task standing Group - - 0.22 0.33 0.24
Pre task standing 84.44 (10.01) 0.22 - 0.84** 0.96**
Speech task 88.64 (12.10) 0.33 0.84** - 0.90**
Post task standing 83.56 (11.30) 0.24 0.96** 0.90** - *p<0.05,
**p<0.01 ***p<0.001
The descriptive statistics show that the heart rate in bpm in the CU+ group was lower (mean=82.07, SD=8.92) in timeslot 1 than the heart rate in bpm in the CU- group (mean= 84.30, SD=7.25). This also accounts for the differences in heart rate in bpm in both groups during timeslot 2 and timeslot 3, as displayed in table 2. These are expected outcomes.
Table 2.
Means and Standard Deviations (SD) of the differences in heart beat (in bpm) in pre task standing, speech task and post task standing.
CU+ (N=9) CU- (N=11)
Mean (SD) Mean (SD)
Pre task standing 82.07 (8.92) 86.38 (10.84)
Speech 84.30 (7.24) 92.18 (14.35)
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Testing the hypotheses and answering the research question
To test the first hypothesis, a mixed ANOVA was used. The mixed ANOVA calculated the differences in average heart rate in bpm between the CU+ and CU- groups and the different timeslots. As expected, the average heart rate in bpm in the speech task was significantly higher (mean= 88.24) than in the pre task standing (mean=84.23) and post task standing (mean=83.30). This analysis showed a significant difference in average heart rate in bpm between pre task standing and speech task (p<0.05) and between speech task and post task standing (p<0.01) (table 3).
Table 3.
Differences in heart rate in bpm throughout the three timeslots.
Mean p
Pre task standing 84.23
Speech 88.24 0,04
Speech 88.24
Post task standing 83.30 0,00
Post task standing 83.30
Pre task standing 84.23 0.70
Note. differences account for whole population (N=20).
Mauchly’s Test of Sphericity was significant (p<0.01), indicating that the test of between subjects cannot be used. Therefore, the test of within subjects was used. This within subjects test (table 4) showed a significant difference between the three timeslots (pre task standing, speech task and post task standing) (p<0.01). No significant difference between the CU+ and CU- groups was found (p>0.05).
Table 4.
Degrees of freedom (df), F and significance of the within subjects test.
df F p
Timeslots 1.55 10.23 0.00
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Indicating that there is no significant interaction between the three timeslots and the two groups, but it shows that heart rate (in bpm) differs in the three timeslots. So, the differences in heart beat (in bpm) throughout the three timeslots is not equivalent in both groups. The mixed ANOVA showed equal variance, because there are no significant differences for pre task standing (F(1,19)=0,04, p>0,05), for speech task (F(1,19)=3.31, p>0,05) and for post task standing (F(1,19)=0,27, p>0,05). This means that there were no significant differences between the heart rate in bpm between the CU+ and CU- groups during the three timeslots.
In order to accept or reject the second hypothesis, a paired sample T-test was performed. After this analysis, a two by two ANOVA was conducted. First, the paired sample T-test was performed to gain information about the differences between the average heart rate in bpm in three timeslots (table 5). The analysis showed a significant difference of heart beat in bpm of the whole population between the three different timeslots (t= -2.86, p=0.01).
Table 5.
Means, Standard Deviation (SD), testing size (t), degrees of freedom (Df) and significance of the paired sample T-test.
N=20
Mean (SD) t Df p
Pre task standing 84.44 (10.01)
Speech task 88,63 (12.10)
Pre task standing – speech task
-4.19 (06.56) -2.86 19 0,01
Based on the significant results of the paired samples T-test, a two by two ANOVA was conducted to study whether the differences in average heart beat in bpm between the CU+ and CU- groups differed. More specifically: to investigate whether the average heart beat in bpm in the CU- group was higher from pre task standing to speech task, compared to the average heart beat in bpm in the CU+ group. Table 6 shows the non-significant results of the two by two ANOVA (F=1.19, p>0.05). When looking at the means of the average heart rate in both timeslots, expected results came out. In the pre task standing and the speech task, the CU+ group did have a lower average heart rate in bpm than did the CU- group.
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Table 6.
Group, Mean (M), Standard Deviation (SD), F and Significance of the two by two ANOVA. CU+ (N=9) CU- (N=11)
Mean (SD) Mean (SD) F p
Pre task standing 82.07 (3.35) 86.38 (3.03) Speech task 84.30 (3.91) 92.18 (3.54)
Wilk’s Lambda 1.19 0.33
Note. Intercept analysis was significant (F=666.82, p<0.001).
The third hypothesis would be accepted if the CU- group did have a faster heart rate recovery after the speech task. First, a paired sample T-test (N=20) was conducted. Here, no distinction was made in CU+ and CU- groups (yet). Table 7 shows the results of this paired samples T-test. The test showed a significant difference of heart beat in bpm of the whole population between the three different timeslots (t= 4.35, p<0.001).
Table 7.
Means, Standard Deviation (SD), testing size (t), degrees of freedom (Df) and significance of the paired sample T-test.
Mean (SD) t Df p
Speech task 88.64 (12.11)
Post task standing 83.56 (11.30) Pre task standing – speech
task
5.07 (5.21) 4,35 19 0,00
Note. Paired samples T-test was conducted with entire population (N=20).
Because the paired samples T-test was significant, a two by two ANOVA was conducted to study whether the differences in average heart beat in bpm between the CU+ and CU- groups differed. Table 8 shows the non-significant results of the two by two ANOVA. Results indicate that there is a difference in average heart rate in both timeslots. In the speech task and the post task standing, the CU+ group did have a lower average heart rate in bpm than did the CU- group.
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Table 8.
Group, Mean (M), Standard Deviation (SD), F and Significance of the two by two ANOVA. CU+ (N=9) CU- (N=11)
Mean (SD) Mean (SD) F p
Speech task 84.30 (3.91) 92.18 (3.54) Post task standing 80.63 (3.76) 85.97 (3.40)
Wilk’s Lambda 0.87 0.31
Note. Intercept analysis was significant (F=0.02, p<0.001).
Girls in the CU- group do not have a significantly quicker heart rate recovery after the speech task than do girls in the CU+ group. The means of the average heart rate in bpm do show an expected effect: the CU- group has a higher average heart rate in bpm during the speech task (mean=92.18) than the CU+ group (mean=84.30). In post task standing, the CU- group still has a higher heart rate in bpm (mean=85.97) than the CU+ group (mean=80.63). The CU- group makes a bigger leap from speech task to post task standing than the CU+ group. This indicates that the girls who do not meet the CU specifier had a quicker and larger drop in average heart rate in bpm than did the girls who do meet the CU specifier. This was an expected effect.
Discussion
The present study investigated the influence of CU traits on heart rate in bpm in girls with conduct disorder during the Trier Social Stress Test. At first, this study tested if girls in the CU+ group had a generally lower basal heart rate in bpm than girls in the CU- group. No significant difference between basal heart rate in bpm between the CU+ and CU- group was found. Heart rate in bpm did however differ significantly between the three timeslots, which indicates that participant did feel stress during the speech task. The mean differences between the CU+ and CU- group did go in the expected direction: girls in the CU- group had a higher basal heart rate than girls in the CU+ group throughout the three timeslots. These results were not significant, but they do indicate that girls who do meet the CU specifier have a lower average heart rate in bpm than girls who do not meet the CU specifier. This stands in line with the findings of Zuckerman (1979, in: de Vries-Bouw e.a., 2011), who state that the low arousal theory can cause the low(er) heart rate in people who show criminal behavior: in order to change their unpleasant physiological state of low arousal, people start to show antisocial and/or delinquent behavior.
18
However, girls who do meet the CU specifier do not have a significantly lower heartrate in bpm throughout the TSST than do girls who do not meet the CU specifier. An alternative explanation for these findings can be given by Steiner, Ryst, Berkowitz, Gschwendt and Koopman (2002), who state that differences between gender in responding to stress situations are enormous. For example, girls rate their negative affect higher during stress than do boys, which can cause an increased heart rate in girls who do meet the CU specifier. Previously performed studies were focused on the differences between man and women and their reaction (both emotionally and psychosomatically) to stress.
The reactivity of heart rate and the differences between this reactivity between the CU+ and CU- group was also tested in this study. It was expected that the reactivity of girls who meet the CU specifier was lower than the reactivity of girls who do not meet the CU specifier. No significant differences between the CU+ and CU- group were found when it comes to their reactivity. In other words: the girls in the CU+ group did not have a significant lower peak in their heart rate in bpm during the speech task than did girls in the CU- group. Even though this difference was not significant, the results did go in the expected direction: the girls in the CU- group were showing a higher peak in heart rate in bpm than did girls in the CU+ group. How come these findings are not significant? According to Matthews and Stoney (1988), the psychosomatic responses to stress of men and women are found to be different. They state that gender and age are important determinants of cardiovascular adjustments in men and women during stress (men do have greater blood pressure responses than women during stress, and boys do have greater systolic blood pressure responses than do girls). Van Goozen et. al. (1998) support this by stating that gender is one of the main individual differences when it comes to ANS responses. Rudolph and Hammen (1999) and Costello et. al. (2003) also emphasize the gender differences when it comes to ANS reactions and coping with stress. According to the authors, girls have more internalizing coping mechanisms than do boys. The hypotheses of this study are based on previous research, mostly done within a population of boys, which can cause the non-significant results found in this study.
Besides the gender differences, age also seems to be an important factor when it comes to differences in ANS reactions (Matthews & Stoney, 1988). According to Kudielka, Buske-Kirschbaum, Hellhammer and Krischbaum (2004), heart rate in elderly people
19
(adults) shows higher peaks and increases while experiencing a stressful event than does heart rate in younger (non-adults) people.
This study expected that the heart rate of girls in the CU+ group would recover more quickly after the stress task than the heart rate of girls in the CU- group. Results showed that the differences in average heart beat in bpm were going in the expected direction: girls in the CU+ group had a quicker recovery and reached their baseline heart rate faster after the stress task than did the CU- group. However, these results were not significant and therefore not stable enough to draw conclusions out of it. According to de Vries-Bouw et. al. (2011), co inhibition is found in boys who meet the CU specifier. This means that there is a weakend heart rate reactivity present, in combination with increased vagal withdrawal. Shetler et. al. (2001) state that heart rate recovery is mediated by vagal reactivation. In male CD, a weakend heart rate reactivity and increased vagal withdrawal is present (Beauchaine & Hong, 2008; de Vries-Bouw e.a., 2011), which causes quicker heart rate recovery after experiencing a stressful event. This autonomic response is found in boys, but – as stated earlier – gender is a major component when it comes to autonomic responses. According to Elsenbruch, Harnish and Orr (1999), males differ from females when it comes to autonomic functioning: males show an increased sympathetic dominance and decreased vagal tone (part of the vagus nerve, which is the most important part of the ANS (Pinel, 2015)). These differences may have caused the non-significant results.
Results of this study are discussible and need further explanation: the results of this study are based on the data of twenty girls, who are all included in the FemNAT-CD study and therefore all meet the criteria for ODD and (at least one or two) symptoms of CD. Therefore, the population is small and monotonous and/or homogeneous. Within this population, the distinction between girls who meet the CU specifier and girls who do not meet the CU specifier is made . Because of the homogeneous, small population, this distinction might have been not strict enough. Therefore, the population of this study might not display a representative selection of the population.
The CU specifier includes the presence of two or more of the following CU traits: lack of remorse or guilt, lack of empathy, shallow or deficient affect and unconcerned about performance (Colins & Vermeiren, 2013; Moffitt e.a., 2008). Because the distinction between the two groups is made this way, girls all meet the CU specifier on a different level. The CU+ group is therefore not homogeneous and therefore the outcomes can be
20
different from expected. In other words: the total population used for this study might have been to homogeneous when it comes to the distinction between CU+ and CU- group. In order to test the influence of stress on female CD and CU traits, this study used heart rate as the autonomic parameter. Previous research containing this parameter was mostly done within a population of boys. The hypotheses of this study were therefore based on data retrieved in boy studies, but this study was completely focused on girls. Perhaps other parameters who measure autonomic responses to stress should have been included to get a completer image. For example, Pajer et. al. (2001) found that girls who have CD have significant lower cortisol levels than do girls who do not have CD.
For future research, it might be useful to add cortisol as a parameter for testing the (autonomic) responses on stress in girls with CD and meet the CU specifier. Another useful adding to future research would be a control group. This way, the CU+ group and the CU- group will differ more, in order to gain more significant differences.
This study distinguishes itself by using heart rate in bpm as a parameter to measure the influence of CU traits in girls while experiencing a stressful event. It has been found that the ANS of girls differs from the ANS of boys. This means that specific knowledge about female CD, CU traits and determinants that influence CU traits in girls must be gained. This is important, because girls often show more internalizing symptoms of CD than externalizing symptoms of CD which leads to wrong clinical diagnoses and therefore inadequate treatment of girls with CD and CU. The findings of this study provide guidelines for future research on female CD and CU. More detailed and more expanded research can help girls with CD and CU to be treated more adequately.
21
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26
Appendix 1: The Youth Psychopathy Inventory
YPIInstructie
Deze vragenlijst bestaat uit een aantal beweringen die gaan over hoe jij denkt en voelt over verschillende onderwerpen. Lees elke bewering goed door en bepaal hoe goed de bewering op jou van toepassing is. Je kunt voor elke bewering kiezen tussen vier verschillende antwoorden.
Geef voor elke bewering aan hoe je er meestal over denkt of voelt en niet alleen hoe je er op dit moment over denkt of voelt.
Voorbeeld:
Ik lees graag boeken.
Helemaal niet Een beetje Redelijk Heel erg van toepassing van toepassing van toepassing van toepassing
1 2 3 4
• Omcirkel het antwoord dat overeenkomt met hoe jij denkt of voelt. • Denk niet te lang na over elke bewering.
Let op:
• Beantwoord ALLE beweringen.
• Kruis per bewering slechts één hokje aan. Belangrijk:
Er zijn geen ‘goede’ of ‘foute’ antwoorden. Je kunt niet beter of slechter scoren dan een ander. We zijn geïnteresseerd in wat jij denkt en voelt en niet in wat ‘goed’ of ‘fout’ is.
27 Helemaal niet van toepassin g Een beetje van toepassin g Redelijk van toepassin g Heel erg van toepassin g 1. Ik ben er graag bij als er spannende
dingen gebeuren 1 2 3 4
2. Ik voel me meestal kalm als andere
mensen bang zijn 1 2 3 4
3. Ik geef liever meteen mijn geld uit dan het
op te sparen 1 2 3 4
4. Ik verveel me meestal snel als er te weinig
afwisseling is 1 2 3 4
5. Ik heb waarschijnlijk vaker gespijbeld van school of werk dan de meeste andere mensen
1 2 3 4
6. Het is makkelijk voor mij om anderen te charmeren of te verleiden zodat ik van ze krijg wat ik wil
1 2 3 4
7. Het is leuk om verhalen te verzinnen en te proberen andere mensen erin te laten geloven
1 2 3 4
8. Ik ben in staat om geen spijt- of
schuldgevoelens te hebben over dingen waarvan ik denk dat andere mensen wel spijt zouden hebben
1 2 3 4
9. Ik beschouw mijzelf als een behoorlijk
impulsief persoon 1 2 3 4
10. Ik ben beter dan iedereen in bijna alles 1 2 3 4 11. Ik kan mensen bijna alles laten geloven 1 2 3 4 12. Ik vind huilen een teken van zwakte, zelfs
als niemand het ziet 1 2 3 4
13. Als ik veel geld zou winnen in de loterij, zou ik stoppen met school of werk en alleen dingen gaan doen die leuk zijn
1 2 3 4
14. Ik ben in staat om mensen te misleiden door mijn charme en glimlach te gebruiken
1 2 3 4
15. Ik ben er goed in mensen mij te laten
28 16. Ik ben vaak te laat gekomen op mijn werk
of op school 1 2 3 4
17. Als andere mensen problemen hebben is het meestal hun eigen schuld en daarom moet je hen niet helpen
1 2 3 4
18. Het gebeurt vaak dat ik eerst wat zeg en
later pas nadenk 1 2 3 4
19. Ik heb talenten die veel verder gaan dan
die van andere mensen 1 2 3 4
20. Het is makkelijk voor mij om mensen te
manipuleren 1 2 3 4
21. Ik heb zelden spijt van dingen die ik doe, zelfs als andere mensen het gevoel hebben dat ze verkeerd zijn
1 2 3 4
22. Ik vind het leuk dingen te doen alleen
maar voor de kick 1 2 3 4
23. Het is belangrijk voor mij om de gevoelens
van andere mensen niet te kwetsen 1 2 3 4
24. Soms lieg ik zonder reden, behalve dan
omdat het leuk is 1 2 3 4
25. Zenuwachtig of bezorgd zijn is een teken
van zwakte 1 2 3 4
26. Als ik de kans krijg om iets leuks te doen, doe ik het en maakt het niet uit wat ik daarvoor aan het doen was
1 2 3 4
27. Als iemand mij iets vraagt heb ik meestal snel een antwoord klaar dat
geloofwaardig klinkt, zelfs als ik het net verzonnen heb
1 2 3 4
28. Als iemand erachter komt dat ik iets fout heb gedaan, voel ik me eerder boos dan schuldig
1 2 3 4
29. Ik verveel me snel als ik steeds hetzelfde
moet doen 1 2 3 4
30. Het zou beter gaan met de wereld als ik
de leiding had 1 2 3 4 31. Om mensen te laten doen wat ik wil,
werkt het voor mij vaak het best om ze te misleiden
1 2 3 4
32. Het gebeurt vaak dat ik dingen doe zonder
29 33. Vaak gedraag ik me charmant en aardig
om te krijgen wat ik wil, zelfs bij mensen die ik niet aardig vind
1 2 3 4
34. Het is meerdere keren gebeurd dat ik iets heb geleend en het daarna kwijt ben geraakt
1 2 3 4
35. Ik word vaak verdrietig of ontroerd als ik droevige dingen op televisie of in een film zie
1 2 3 4
36. Ik word meestal niet angstig van dingen
waar anderen wel bang van worden 1 2 3 4
37. Ik ben belangrijker en waardevoller dan
andere mensen 1 2 3 4
38. Als het nodig is, gebruik ik mijn glimlach
en mijn charme om anderen te gebruiken 1 2 3 4
39. Ik snap niet hoe mensen zo geraakt kunnen zijn dat ze gaan huilen als ze naar de televisie of een film kijken
1 2 3 4
40. Ik heb/had bijna nooit mijn school- of
werkopdrachten op tijd af. 1 2 3 4
41. Ik ben voorbestemd om een bekend, belangrijk en invloedrijk persoon te worden.
1 2 3 4
42. Ik vind het leuk om spannende of gevaarlijke dingen te doen, zelfs als het verboden of illegaal is
1 2 3 4
43. Soms merk ik dat ik lieg zonder een
speciale reden 1 2 3 4
44. Schuld of berouw voelen over dingen waarmee je andere mensen gekwetst hebt, is een teken van zwakte
1 2 3 4
45. Ik laat mij niet zo veel beïnvloeden door mijn gevoelens zoals andere mensen dat lijken te doen
1 2 3 4
46. Het is voorgekomen dat ik misbruik maakte van anderen (andere gebruikte) om te krijgen wat ik wilde
1 2 3 4
47. Ik vind het leuk om aan te dikken of te
overdrijven als ik over iets vertel 1 2 3 4
48. Je schuldig voelen of spijt hebben van iets als je iets fout hebt gedaan, is zonde van de tijd
30 49. Ik word meestal verdrietig als ik andere
mensen zie huilen of als ze verdrietig zijn 1 2 3 4 50. Ik ben vaak in de problemen gekomen
