Affective theory of mind impairments linked with callous-unemotional traits implicate cognitive control: A pre-registered double-blind randomized controlled trial with a dual-task paradigm

Background: Antisocial behavior in youth can encompass both conduct problems (CP; e.g., aggression, rule-breaking) and callous-unemotional (CU) traits (i.e., limited empathy, remorse, and guilt). CP are associated with pronounced and broad cognitive difficulties whereas CU traits have stronger links to disrupted affective theory of mind (ToM) and more specific cognitive difficulties involving cognitive control. Cognitive control difficulties have been linked to affective ToM among early adolescents with elevated CU traits, suggesting an interaction between cognitive and affective processing that are unique to CU traits. Here we sought to improve on those initial findings by leveraging a randomized dual-task (within-trial) design to replicate and extend prior findings.Trial design: The preregistered study leveraged a double-blind randomized controlled trial using a dual-task design. The dual-task used an inhibitory processing task as a secondary task to impose additional demands on cognitive control implicated in ToM to compete with a primary ToM task with cognitive, affective, and physical ToM condition. Participants were randomized into control and test conditions using a permuted block randomization stratified by sex at birth and severity of CU traits. The order of single ToM task or dual-task was counterbalanced to test within subject effects of cognitive control on affective ToM inferences. Methods: A total of 85 participants (47% female) were used in the final analysis. Primary and preregistered hypotheses were tested using a repeated measure random effect model that accounted for individual variance and tested fixed effect interactions for CU and CP with group across time. Outcomes tested involved change in accuracy and reaction time from single ToM to dual-task. Secondary analysis examined contrasts between ToM trial types, dual-task effect, and single ToM task performance as well as associations with antisocial behaviors. Results: CU traits were independently associated with decrements in affective ToM from single to dual-task for both accuracy and reaction time, as well as secondary contrast tests when comparing affective > physical and cognitive trials. CU traits were also related to greater dual-task effects indicating greater difficulty in ToM after taxing cognitive control. CP were related to decrements at baseline ToM task performance but were not associated with changes after taxing cognitive control during the dual-task. Importantly, a subset of participants appeared to be resilient to dual-task effects reported lower baseline antisocial behavior even at elevated CU traits. Conclusions: Resource limitations for cognitive control in those elevated in CU traits is an important mechanism underlying difficulty utilizing affective data from the environment to inform social behavior. Those less vulnerable to additional demands on cognitive control reported fewer antisocial acts even at higher CU traits. Overall, findings suggest specific cognitive-affective interactions that relate to CU traits and explain real world antisocial behavior. This is a novel mechanism outside of the traditional cognition or affect etiologies that may indicate a developmentally specific mechanism critical in the study and treatment of youth antisocial phenotypes and development of psychopathy in adulthood.