Personality Disorders


Dr Gregor Kowal
Specialist in Psychiatry and Psychotherapy,
German Board Certified,
Medical Director,
Clinic for Health and Medical Care
Phone: 00971-4-4574240

The theory on borderline personality organization was conceptualised by Otto Kernberg. He is a psychoanalyst and professor of psychiatry at Weill Cornell Medical Colleg. His integrative writings were central to the development of modern object relation theory, a theory that is perhaps the most important achievement in the developement of modern psychoanalysis.

The concept of personality structure in Otto Kernberg:

“This organization types of neurosis, borderline state, and psychosis are reflected in the dominant personality characteristics of the patient, especially with regard first of the degree of identity integration, 2 of the types of defenses, that he uses common, 3 of its ability to test reality. I believe that the neurotic personality structure, in contrast to the structures of borderline states and psychosis, an integrated identity implies. The neurotic personality structure has a defense organization that is centered on repression and other defense mechanisms of the middle or higher level. In contrast, on to structures of borderline states and psychoses in patients who dominate primitive defense mechanisms, center the is the mechanism of cleavage. The reality check is in the personality organization of the neurotic and borderline patients received, in that of the psychotic but is significantly affected . These structural criteria can complement the usual behavioral or phenomenological descriptions of patients and contribute to greater accuracy and differential diagnosis of mental illness, especially in hard-classifiable cases. Additional criteria that help differentiate the borderline personality organization of the neuroses, are the presence or absence of non-specific manifestations of Ichschwäche, particularly of anxiety tolerance, of impulse control and ability to sublimation and ? for the differential diagnosis of schizophrenia ? the presence or absence of primary process thinking in the clinical situation ?. The level and quality of superego integration are additional, for the prognosis important structural features contributing to differentiate between neurosis and borderline personality structure. “

In the following interview explains Otto Kernberg his view on the psychoanalitic concept of personality disorders and psychoanalisis.

The Seeds of the Self

An interview with Otto Kernberg

by Susan Bridle



We were delighted when Otto Kernberg?one of the primary engineers of the theory?squeezed an hour into his busy schedule to speak with us. Kernberg, who at age seventy-two still works a seventy-plus-hour workweek, is a renowned psychoanalyst, clinical researcher, developmental theorist, psychiatric treatment innovator?and a legend in the annals of psychology. A native of Vienna, he immigrated to Chile with his parents during the Second World War. He earned his undergraduate, medical and psychoanalytic degrees in Santiago, where he began his professional and academic career in the 1950s. Dr. Kernberg is not only a principal architect of object relations theory but is also widely regarded as the world`s leading expert on borderline personality disorders and pathological narcissism. Current President of the International Psychoanalytic Association, founded by Sigmund Freud in 1908, he is also Director of the Personality Disorders Institute and the Cornell Psychotherapy Program at The New York Hospital, Cornell Medical Center and Professor of Psychiatry at the Cornell University Medical College. He is the author or coauthor of thirteen books as well as dozens of research papers.

In his more than forty years of research, including clinical work with severely disturbed patients, Dr. Kernberg has inquired with laser-like precision into the subatomic components of the psyche and identified what he believes are the most fundamental building blocks in the construction of self-identity. In our conversation, as he walked me through the basics of object relations theory, I was drawn with him into looking at human experience through the piercing clarity of the object relations microscope. I began to grasp intellectually, intuitively and even experientially his intricate vision of how the separate sense of self gradually takes shape from the moment of birth?how undifferentiated fragments of raw experience eventually cohere into emotionally charged images of self and others, and progressively coalesce into an integrated, internalized sense of self and an integrated inner “representational world” of others. Indeed, after a course in object relations from Kernberg himself, or after reading the books in which he outlines his theory, it`s hard not to be convinced that selfhood is not inherent in human experience from birth, but is in fact entirely a mechanically constructed phenomenon.


Speaking with Dr. Kernberg about the nature of the ego was meeting a visionary, encountering a mind with rare quality of attention, expanse of perspective and subtlety of discrimination. He possesses an unusual flexibility and originality of thought that easily embraces subjects normally beyond the scope of traditional psychoanalytic thinking, making him not only a defender of Freud`s genius but a Freudian revisionist with a mission for psychoanalysis in twenty-first-century society and culture. I was honored to have the chance to explore the mystery of the seeds of the self with one of modern psychology`s foremost pioneers.


WIE: Could you please define the word “ego” as you have come to understand it?

OTTO KERNBERG: The ego is an invention of the English translation of Freud`s “Ich.” “Ich” in German means “I,” and it refers to the categorical “I,” or to what also is called the “self,” insofar as it has a subjective quality to it. Freud never clearly differentiated theimpersonal, structural quality of what “ego” means in English from the subjective quality that the word “ich” signals in German. James Strachey, in his translation of Freud, tried to make him sound more scientific by bringing in Latin terms and making everything more precise. In the process he decreased somewhat the fluidity, humanity, warmth and flexibility of Freud`s terminology and the poetic aspect of Freud`s writings.

It is true that Freud in 1923 started to describe his “Ich,” his “I,” his “self,” as a structure of the psychic apparatus in contrast to the id and the superego. And this was then picked up by the ego psychologists, particularly in this country. Many characteristics of the ego have been defined. The ego is the seat of consciousness; it`s the seat of perception. The ego controls motility; the ego controls unconscious defense mechanisms; the ego is the integrating agency that brings together the demands of external reality and the superego. While all of this sounds a little mechanical, they are impersonal functions, and classical, pureego psychology went in that direction, losing touch with the subjective quality of the self-concept. So this is why nowadays there has been a reaction against this.

Object relations is a contemporary psychoanalytic theory that puts the emphasis on the importance of earliest relations with significant others as the building blocks of the construction of the tripartite structure of ego, superego and id. More specifically, from birth on, our relations with significant others, under the impact of strong affects [emotions], are internalized as affective memory. These basic affective memories contain the representation of the self, the representation of other?called “object” in object relations theory?and the dominant affect linking them. There are many of these dyadic structures of self- and object-representations that eventually consolidate. All the self-representations are eventually integrated as an integrated self. And that integrated self practically corresponds to the “I,” to the categorical “I” or categorical self of the philosophers.

In simple terms, one might say that from birth on we have an inborn capacity for perception, for memory, for establishing representations of what is perceived, and gradually we develop symbolic thinking and the capacity for abstract thinking and intelligence. We absorb what`s going on around us, our relationships with things and with people. The ego is like a computer, absorbing information, integrating it and learning how to sort out what is important from what is not; what is good, what is bad; what is helpful, what is damaging. We learn the control of our own body, and we gradually learn to differentiate what`s inside from what`s outside. And eventually, an internal world is built up. Part of this remains in conscious memory, in consciousness?a small part. And a large part goes into unconscious memory, into what is called the “preconscious.”The preconscious is like a reservoir of information that we don`t think about all of the time, but that we have access to. And part goes into a still deeper level, the dynamic unconscious or the id.

Now, what`s in that dynamic unconscious or the id? All of that which the ego or self cannot tolerate in consciousness. It`s just too intense; it`s too dangerous, and it tends to get forbidden. Freud said that what are particularly intense and tend to get forbidden are early sexual impulses and desires and early aggressive impulses and desires.

So the ego has the double task of general learning as well as setting up an internal world of representations of self and others. And these representations are gradually integrated, so then the ego develops an integrated sense of self and an integrated sense of significant others?an internal world of the people we love and who love us?or what Joseph Sandler called the “representational world.”

The ego, in short, is the seat of consciousness, of perception, of motor control, of conscious memory, of access to the preconscious. But also?and very fundamentally?it`s the seat of the world of internalized object relations and an integrated sense of self.

WIE: Many spiritual traditions define the ego very differently from the way that the psychoanalytic tradition usually speaks about it. In fact, the ego is seen not as something that we would want to cultivate or develop, but as the very force within us that we must do battle with and ultimately extinguish if we want to evolve spiritually. In these traditions, the ego is understood to be the force of narcissism and self-centrism and as the insatiable and fundamentally aggressive need to always see ourselves as separate from others. These traditions see the ego, in this sense, as the enemy on the spiritual path?as that which thwarts our higher spiritual aspirations. In your work, have you encountered anything like this within the human personality?

OK: I`m familiar with this approach to spirituality; one finds this particularly in Eastern religious movements. However, it seems to me that there are semantic problems here. There is a psychoanalytic concept of narcissism. At the clinical level, “narcissism” refers simply to self-love, self-esteem and, at a more theoretical level, to the investment in the ego with libidinal energy. When Freud coined the concept of narcissism, he assumed that libido was first invested in the self and then later displaced onto others. And eventually, a certain equilibrium is established by which one invests both self and others with libido or love. One implication of this early formulation is that if there is too much self-love, there is not a lot left for loving others. And if there is too much altruism, there is not much love left for self. This early formulation, however, has been questioned in the light of later findings. Now, the dominant psychoanalytic thinking is that the loving investment in self and in others occurs simultaneously and that under normal conditions, self-love and love of others go together. Those happy natures who have been treated well are at peace with self, can be very secure, love themselves?and at the same time be very committed to others.

This is very different from abnormal conditions in which there is abnormal self-love. Pathological narcissism is what is usually called an “ego trip.” This is an individual with an exaggerated love of self and in whom there is a devaluation of others. There is an impoverishment of that internal world of significant others, the representational world that I described to you. So these individuals who are very full of themselves at the same time don`t have an internal world of representations of significant others nor the richness of an internal moral world, and they are excessively dependent on being admired and accepted by others. On the one hand, these people are very grandiose, yet on the other, they are easily hurt, feel easily rejected and easily can get very envious and resentful of other people who don`t suffer from the same hypersensitivity that they do. When you have somebody with what`s perceived as a very great ego, that usually indicates the existence of abnormal narcissistic structures, where the love is invested in self with a kind of grandiosity, entitlement and ruthlessness. There is also a sense of emptiness that goes with this because the richness of life comes from our gratifying intimate relations with significant others as well as from our appreciation of ideals that are outside of us, for example, in the area of truth or science, or the area of aesthetics or art, or in the area of religion and moral values. People with an abnormal grandiose self-sense cannot invest normally in these values, and their life is impoverished.

So from the psychoanalytic viewpoint, the idea that spirituality implies an effort to reduce the importance of the ego, of narcissism, in order to open oneself up to religion, to art, to truth, holds true for narcissistic pathology, but not necessarily for normal self-esteem or self-regard. That should be harmonious with spiritual development. And there is a natural religiosity that is part of normal development, reflected by all of the trends toward developing an integrated internal moral system.

Psychoanalysis has nothing to say about the existence of God?that`s a philosophical problem, not a psychological one. But certainly there`s something to say in the sense that religiosity is a profound human need and that the religions?or universally organized moral systems directed to protect what is good against evil?make eminent sense from a psychological viewpoint because evil exists. It exists in the sense that primitive aggression is always there as a potential in the human mind. It shows up not only under abnormal conditions of the individual but it also shows up when there are what we call “regressive group situations,” regressive mass psychology situations in which aggression can rapidly take hold and, therefore, represents concretely what we call “evil.”

WIE: Traditional religious or spiritual perspectives tend to see these matters as more absolute; there is not a distinction between “normal” and “healthy” narcissism?and, in fact, “healthy narcissism” would be seen as an oxymoron because, from this point of view, anyform of narcissism would be seen as a negative expression of self-centrism and failure to show awareness of and concern for others. From this perspective, the seeds of narcissism are the seeds of corruption and evil. Based on your experience as a psychoanalyst, do you think that it is possible to uproot all vestiges of negative narcissism within the self? Is this an ideal that you would even encourage people to strive for?

OK: Well, again, the idea that spirituality and narcissism cannot go together I think is a mistake, because it does not properly differentiate between normal and abnormal narcissism, as I have explained. Secondly, by the same token, one cannot say that the evil in the world is constituted by narcissism. But it is significantly constituted by pathological narcissism. And I would add even further, it is constituted not just by any pathological narcissism but by the most severe forms of it?in which there is a particular malignant development that consists of a return to primitive aggression and an idealization of the self as an aggressive self with power over others. This pathological idealization of the self as an aggressive self clinically is called “malignant narcissism.” And this is very much connected with evil and with a number of clinical forms that evil takes, such as the pleasure and enjoyment in controlling others, in making them suffer, in destroying them, or the casual pleasure in using others` trust and confidence and love to exploit them and to destroy them. That`s the real evil?that synthesis between pathological narcissism and primitive aggression. And we find that at the level of individuals and in groups as well. Sometimes we find it in organizations. We find it in certain fundamentalist ideologies; we find it in certain aspects of mass psychology. That`s the real evil.

But to answer your question: No, it is not ideal to divest everybody of narcissism because normal narcissism is a source of pleasure in living, of enjoyment of self, enjoyment of healthy self-affirmation, healthy aggression, enjoyment of sexuality, eroticism, love, intimacy. This is all part of normal narcissism. And what I am trying to say, in essence, is that I see no contradiction between normal narcissism and the spiritual orientation, although there is all the contradiction in the world between abnormal narcissism and spirituality.

WIE: Within many religious teachings, a central aspect of spiritual practice is rigorous self-inquiry, in which one looks deeply into the nature of one`s motivations. In this self-inquiry, one confronts and comes to terms with some of the narcissistic tendencies you were just describing?albeit in a much subtler form than these extreme cases. In the religious traditions, one is looking at this negative narcissism?it`s still negative or malignant narcissism rather than positive narcissism?but it`s at a subtler level, and it`s this that the spiritual practitioner is trying to root out from within their motivations and from within their psyche.

OK: Yes, I understand that. In fact, the goal of psychoanalysis is to increase our self-knowledge of the unconscious motivations of behavior. Freud at one point said that there will always be objection to psychoanalysis, that he has brought a plague to humanity. What he meant was that we all have primitive, antisocial impulses, sexual desires, aggressive desires, that run counter to the needs of culture. Under the best of circumstances, these are transformed into culturally useful and positive elements. Under the worst of circumstances, they become evil. What I`m trying to say is that the deepest, unconscious motivations have in them the seeds of both good and evil. I agree that self-reflection and an honest search for one`s unconscious motivations increases knowledge and meaning in life. It has been said that “only an examined life is worth living.” And psychoanalysis has helped with that. This searching self-reflection for unconscious motivations may provide not only greater knowledge of the self but also may help to free oneself?at least in part?of the destructive aspects of repressed conflicts. In this regard, self-reflection and an honest search for one`s motivations helps spirituality, but it does not necessarily bring happiness; it also brings the pain and sorrow of discovering that we are less ideal than we wanted to think ourselves.

WIE: In many Eastern religious traditions, the highest goal of human evolution is called enlightenment. One way of defining enlightenment is that it is a condition in which one is utterly awake and in touch with reality exactly as it is. It is a condition in which one is no longer motivated in any way to distort reality, to preserve one`s self-image, or to support any personal bias or agenda. In this view, the ego is seen as a distorting mechanism, as the colored glasses that must be removed if we are to be able to see things as they are and to respond to life with true integrity. Now, one of the central activities of the ego is the screening or distorting mechanisms by which impressions or information that contradict or challenge one`s self-image or worldview are selectively ignored or distorted. Do you think it is possible to reach a state where one is no longer compelled to screen anythingout to protect one`s self-image or worldview? Do you think it is possible to attain a condition where one has no need or motivation whatsoever to distort reality in any way and, therefore, is able to be completely in touch with reality exactly as it is?

OK: I think that there are certainly degrees of freedom from distortion, and I would say that a function of the normal ego is to try to achieve enlightenment in the sense of decreased distortions and being able to see reality?both external and internal?as it is. But it seems to me that this is an ideal state that is reached only partially by most people and most likely not as a permanent condition, but oscillating. In other words, there are always unconscious needs that influence us; the shadow of our dynamic unconscious colors all of our perceptions, and it is almost inhuman to be able to free oneself completely from that. So I would say that enlightenment as you describe it seems to be a road, an aspiration. But I would seriously question that possibility in an absolute sense?except perhaps for extremely gifted, unique individuals whom we would consider saints. And even those probably have achieved such a condition only in a transitory way.

WIE: Harvard psychiatry professor George Vaillant, in his book The Wisdom of the Ego, asserts that ego defenses are not pathological or symptoms of mental illness, but are in fact ingenious resources of the psyche for adaptation and even creativity. He says, “At times we cannot bear reality. At such times our minds play tricks on us. Our minds distort inner and outer reality so that an observer might accuse us of denial, self-deception, even dishonesty. . . . But often such emotional and intellectual dishonesty is not only healthy but also mature and creative.” Do you agree that emotional and intellectual dishonesty is often not only healthy but mature and creative? Or do you believe that a truly healthy human being is one who is undefended?

OK: I think that everything he`s saying is correct. I would just change some of the emphasis, in the sense that while it is true that self-deception may occasionally be life-saving, in general, the more severe forms of primitive defensive operations tend to weaken the ego. Denial, for example, is a defense that may be helpful sometimes. There are certain conditions, such as when an individual hears terrible news?about a mortal illness, or about the death of a close relative or some other major tragedy?andthey react with a kind of a defensive numbness. This is a form of denial, but it may be a denial that helps survival. Defense operations may help survival and protect functioning under certain conditions. But, in general, it is of course true that the more we tolerate reality, the better off we are.

WIE: What is the ultimate goal of psychoanalysis? What do you think is the highest human potential with regard to ego health and development?

OK: In very simple terms, Freud said that the goal of psychoanalysis was to help individuals to be able to work and to love. And to expand a little on it, I would say the goal of psychoanalysis is to free individuals from the restrictions of unconscious conflicts and the defenses related to them, as well as to resolve a lack of integration of the internal realm of object relations?in order to permit people to commit themselves to work, to creativity and to mutuality of love relations. Also, to open themselves up to the scientific, moral and aesthetic perspectives. And of course, more specifically, to resolve thesymptoms for which the patient comes to treatment. But these would be the most general goals.

WIE: Object relations theory has been adopted by many contemporary transpersonal psychologists, particularly those with training in Buddhist psychology and philosophy, because it seems to support the Buddhist teaching that there is no self?that we are not born into this world as an independent entity in the way we think we are, but rather that our independent sense of self is actually a delusion, an illusory manifestation of mutually dependent coorigination. Transpersonal therapist and teacher of Buddhist philosophy Jack Engler writes, “Both Buddhist psychology and psychoanalytic object relations theory define the essence of the ego in a similar way: as a process of synthesis and adaptation between the inner life and outer reality which produces a sense of personal continuity and sameness in the felt experience of being a `self,` a feeling of being and ongoingness in existence. . . . In both psychologies, the sense of `I,` of personal unity and continuity, of being the same `self` in time, in place and across stages of consciousness, is conceived as something which is not innate in personality, but is evolving developmentally out of our experience of objects and the kinds of interactions we have with them.In other words, the `self` is literally constructedout of our experience with the object world. This `self` which we take to be `me` and which feels so present and real to us is actually an internalized image, a composite representation.” So, my question is: Are we now, the two of us having this conversation, two composite representations of the many internalized images that have arisen out of our encounters with the object world? Or, is there a self that exists prior to or beneath this process? Is there a self independent of the whole process of object relations development?

OK: I don`t think that the self is an illusion. I believe that`s wrong. But it is true that the self is an entity of subjective experience, sameness, continuity and differentiation from others that is constructed out of our experiences with significant others from the beginning of life. That is true. From the beginning of life there`s a sense of subjectivity that develops in the context of relations with others whose representations or images we take in and that shapes our representations of ourselves. And those multiple representations of ourselves eventually coalesce to form an integrated self, which is a reflection of the integration of our subjective experiences in our interactions with others from the beginning of life. And it becomes a very important central agency in organizing one`s subjective life, one`s relations with others and one`s character?that is to say, the dynamic organization of habitual behavior patterns.

WIE: You said that prior to the whole process of integrating self- and object-representations, there`s a subjectivity that is present?

OK: There is a capacity for subjective experience of pleasure and pain, for registering representations and establishing memories?from birth on. That imagery gradually consolidates as multiple dyadic representations of self and object.

WIE: Could we in some sense say that this subjectivity, this experiencer, isthe self? A self, in some sense, that exists independent of self- and object-representations?

OK: No. I wouldn`t say that. I would say that there are fragmented self-experiences from birth on that gradually coalesce and are integrated. And, eventually, there is an integrated self that relates to integrated representations of significant others. The self is always in relation to significant others. Again, the experiencer, the person who experiences, has early self-experiences, and these are the self-representations that finally coalesce into an integrated, cohesive, subjective sense of self.

WIE: The subjective experiencer itself, prior to the content of experience?what would you call that?

Simply the capacity of the central nervous system to acquire a sense of subjectivity?subjectivity that has elements of pleasure and pain and that registers the perceptions of the external world in the form of memories.

Source: EnlightmentNext Magazine


Can Positive Parental Reinforcement Counter Genetic Risk for Callous-Unemotional Behavior?

(Source American Journal for Psychiatry 01.09.2016)

Conduct problems are a common reason for a childhood referral to mental health and educational services and represent a substantial public health cost. Callous-unemotional behaviors, indicative of lack of empathy and remorse, characterize children who are at risk of developing persistent conduct problems. Previous research indicates that callous-unemotional behaviors are moderately to highly heritable and that conduct problems that co-occur with high levels of callous-unemotional behaviors may be more heritable than conduct problems that do not co-occur with these behaviors.

Children with conduct problems and callous-unemotional behaviors may be genetically vulnerable to developed persistent antisocial behavior. However, for complex behaviors genetic vulnerability does not equal destiny for developing a particular outcome; there are no genes that directly code for callous-unemotional behavior. Genes code that influence characteristics such as neurocognitive vulnerabilities that may in turn increase risk for developing callous-unemotional behaviors and conduct problems. Although an individual’s genome likely limits a so-called reaction norm, it does not mention how an individual will turn out. Genetic variants that are associated with callous-unemotional behaviors are likely to confer advantages as well as disadvantages, depending on the environmental context.

Harsh and negative parenting has been associated with higher levels of callous-unemotional behaviors, whereas a warm parental style has been associated with lower levels of callous-unemotional behaviors in children. Parents with genetic risk factors for antisocial behavior are likely to display parenting behaviors in line with these risks. A part of the association between less than optimal parenting strategies and conduct problems/callous-unemotional behaviors may represent a passive gene-environment correlation, which has been demonstrated for antisocial behavior. Children with conduct problems and callous-unemotional behaviors typically show diminished empathy for others, display less remorse, manipulate others, and do not seem to want to please adults or readily show affection to others and so they are extremely challenging to parent.

It observed protective benefits of environmental influences, including positive reinforcement in toddlerhood, may not be maintained throughout childhood, and other developmentally specific genetic and environmental factors may take over. These include genetic factors pertaining to the maturation of those brain areas involved in planning, impulse control, and complex social interactions, as well as developmentally specific environmental risk factors, such as peer relationships and neighborhood factors.

It is important to bear in mind that parents in adoptive families are typically highly motivated to undertake the challenges of parenting and are also often well resourced. By contrast, in biological families, parents of children with callous-unemotional behaviors are likely to have a host of genetic and contextual risk factors, which can pose challenges for promoting interventions that seek to increase positive reinforcement behaviors toward the child. The efficacy of such interventions in biological families as well as the size and the duration of any beneficial impact on callous-unemotional behaviors and conduct problems must be established.


Heritable and Nonheritable Pathways to Early Callous-Unemotional Behaviors

(Source: American Journal of Psychiatry, 08.04.2016)

Compelling evidence that severe maternal antisocial behavior increases risk for early callous-unemotional behaviors in offspring via genetic pathways. However, positive reinforcement from adoptive mothers was a nonheritable predictor of lower levels of callous-unemotional behaviors, and it buffered against heritable risk. These findings highlight a specific gene-environment interaction in the development of callous-unemotional behaviors and emphasize that positive parenting can reduce risk for early warning signs of future antisocial behavior. This conclusion emphasizes the importance of positive reinforcement in parenting-based interventions for callous-unemotional behaviors and provides a critical message for parents and others working with children with early antisocial behavior: Early callous-unemotional behaviors are heritable and can identify those at risk for continued antisocial behavior; however, these behaviors are malleable, and positive reinforcement from parents can alter these risky pathways.

Callous-unemotional behaviors in early childhood signal higher risk for trajectories of antisocial behavior and callous-unemotional traits that culminate in later diagnoses of conduct disorder, antisocial personality disorder, and psychopathy. Studies demonstrate high heritability of callous-unemotional traits. It also indicates that positive parenting protects against the development of callous-unemotional traits, but genetically informed designs have not been used to confirm that these relationships are not the product of gene-environment correlations.

Despite limited or no contact with offspring, biological mother antisocial behavior predicted early callous-unemotional behaviors. Adoptive mother positive reinforcement protected against early callous-unemotional behaviors. High levels of adoptive mother positive reinforcement buffered the effects of heritable risk for callous-unemotional behaviors posed by biological mother antisocial behavior.

Serious antisocial behavior is a key feature of the psychiatric diagnoses of conduct disorder in youths and antisocial personality disorder in adults. Given their high cost, serious antisocial behaviors, such as aggression, violence, and rule breaking, are a major public health concern. For example, a recent study found that each adolescent diagnosed with conduct disorder cost society $14,000 more per year than other high-risk adolescents. With a lifetime prevalence of 10% for conduct disorder, the financial implications of antisocial behavior are staggering. Additionally, these behaviors have broader, immeasurable occupational, health, social, and emotional costs for perpetrators, victims, and their families. Decades of research have shown that the most severe trajectories of antisocial behavior start in early childhood. Thus, However, the effectiveness of interventions remains limited, and the marked heterogeneity of individuals with antisocial behavior may contribute to this problem. If the etiologies of specific forms of antisocial behavior can be established, then more effective targeted, personalized interventions can be developed.

To address heterogeneity in early-onset antisocial behavior, a specifier was added to the diagnosis of conduct disorder in DSM-5 to assess the presence of callous-unemotional traits (“limited prosocial emotions”). Callous-unemotional traits, characterized by low empathy, callousness, and low interpersonal emotions, identify youths with severe, chronic, and stable antisocial behavior. Studies demonstrating distinct neural correlates and higher heritability of antisocial behavior in the presence of callous-unemotional traits suggest that antisocial behavior with and without callous-unemotional traits has different etiological pathways.

Twin studies suggest that callous-unemotional traits in middle childhood are highly heritable (heritability estimates range from 0.45 to 0.67). However, twin studies of callous-unemotional traits have not identified specific heritable parental traits that put children at greater risk for callous-unemotional behaviors. An important parental behavior that may signal genetic risk for callous-unemotional behaviors is biological parents’ antisocial behavior. Specifically, history of severe antisocial behavior may be indicative of heritable pathways to callous-unemotional behaviors because of the overlap between later callous-unemotional traits, psychopathy, and severe antisocial behavior. Such gene-environment correlations, present in most observational study designs, make it difficult to differentiate genetic from environmental contributions. An adoption design, particularly one in which children are adopted soon after birth, allows for an examination of heritable and nonheritable pathways because biological parents do not provide the rearing environment. Thus, the first goal of the present study was to use an adoption design to examine inherited pathways from biological mothers’ antisocial behavior to early child callous-unemotional behaviors.

However, most typical studies of biological parents rearing their own children cannot rule out the possibility that associations between parenting and child behavior are attributable to genes that influence both parenting and child behavior, a notion supported by a monozygotic twin differences study finding little evidence for harsh parenting as a nonshared environmental predictor of callous-unemotional behaviors. Thus, genetically informed research is needed to examine whether positive parenting directly contributes to the development of callous-unemotional behaviors beyond shared genes.

Finally, because parenting-focused interventions often aim to reroute the trajectory of children with early forms of antisocial behavior by increasing positive parenting, an important question is whether positive parenting can protect against the emergence of callous-unemotional behaviors in the context of high genetic risk for these behaviors.

A longitudinal component by testing whether observations of adoptive mothers’ positive reinforcement when children were 18 months old predicted lower levels of callous-unemotional behaviors at 27 months. Parenting moderated inherited influences on callous-unemotional behaviors by examining whether the link between biological parent antisocial behavior and child callous-unemotional behaviors was significantly attenuated for children whose adoptive mothers demonstrated high levels of positive reinforcement, “good job,” “thanks for picking that up”) were summed, leading to a proportion of positive reinforcement based on the length of the task.

Specific heritable pathway to callous-unemotional behaviors, as biological mother antisocial behavior predicted child callous-unemotional behaviors in the late toddler period. It is also demonstrated that parenting prospectively predicts early callous-unemotional behaviors even when parents are not genetically related to the child. Additionally, an important gene-environment interaction whereby more positively reinforcing mothers buffered inherited risk for early callous-unemotional behaviors was found out. Evidence for the importance of parenting in the face of inherited risk is critical for parenting-focused intervention efforts, as the results emphasize that positive reinforcement from parents can help buffer existing genetic risk, even in children at high risk for persistent antisocial behavior. This message is particularly important when discussing a “highly heritable” set of behaviors, because these findings emphasize that heritability is not destiny. Even children with risk for later callous-unemotional behaviors can have their behavior sculpted by high levels of positive reinforcement.

As poor eye contact has been studied as an endophenotype for callous-unemotional traits, this research has been interpreted as supporting a possible genetic link from parental psychopathic traits to mechanisms involved in the development of child callous-unemotional traits. Given theoretical links between later callous-unemotional traits and interpersonal deficits found in adult psychopathy, it would have been ideal to examine whether biological parent psychopathic traits were related to early callous-unemotional behaviors.

Beyond heritable pathways, our results provide convincing evidence that parenting is important in the development of callous-unemotional behaviors. Parenting during the toddler years becomes increasingly difficult as toddlers gain more mobility and autonomy without concomitant self-regulation skills. Thus, parenting during these years is critical to promoting positive behavior trajectories. Empathy, prosocial behavior, and guilt also develop during this period, making it an important time in the pathway toward the development of callous-unemotional traits and serious antisocial behavior. Moreover, as early callous-unemotional behaviors may also evoke harsher parenting, preventing callous-unemotional behaviors early in life may attenuate the development of transactional, cascading coercive cycles of behavior between parents and children that contribute to serious antisocial behavior.

Positive reinforcement may be particularly important for preventing callous-unemotional behaviors, as a mutually warm relationship can set the foundation for the development of empathic concern. Our findings augment studies in early childhood demonstrating that reduced quality of positive affective interactions between parent and child, including lower eye contact, lower observed dyadic warmth, and lower maternal sensitivity, appears to be a risk factor for callous-unemotional behaviors. Thus, not surprisingly, high levels of positive reinforcement by adoptive mothers were effective at buffering inherited risk, attenuating the effect of biological mother antisocial behavior on later callous-unemotional behaviors. This interaction emphasizes the malleability of early callous-unemotional behaviors and suggests that positive reinforcement should be emphasized in interventions for early callous-unemotional behaviors.

Although our study had several strengths, including an innovative adoption design with a large number of children adopted soon after birth, observational measures of parenting, and assessment of callous-unemotional behaviors during a critical developmental period, it also has a few limitations. We did not measure psychopathy or related constructs in biological parents.

Adoptive families had greater resources (i.e., family income >$100,000 per year) and fewer risk factors, while biological families had lower resources and more risk factors for antisocial behavior than families in the general population. In translating these findings to clinical settings, it is important to consider the relatively high heritability estimates for callous-unemotional traits and our findings of heritable associations between parent antisocial behavior and child callous-unemotional behaviors. Thus, in a “typical” family, children with high levels of callous-unemotional behaviors, who are in the most need of positive parenting, are also more likely to have parents with greater genetic risk and more contextual risk factors for antisocial behavior (e.g., low income, high family stress), who may engage in harsher forms of parenting. These parents also may be less likely to seek intervention services.

Interventions that meet families in their communities, have regular contact with families, increase social support, and increase motivation for change may be more effective in engaging these families in which children have high heritable and nonheritable risk.