Health Service Utilization in Adolescents Following a First Arrest: The Role of Antisocial Behavior, Callous-Unemotional Traits, and Juvenile Justice System Processing.

Previous research indicates that youth exhibiting antisocial behavior are at risk for utilizing a disproportionate amount of health services compared to youth without these problems. The present study investigates whether being processed by the juvenile justice system and showing callous-unemotional (CU) traits independently predict health service utilization (medical and mental health service use and out-of-home placement) over and above the severity of antisocial behavior across adolescence. A total of 766 participants who had been arrested for the first time in adolescence provided data at ten appointments over a period of seven years. Results showed that self-reported antisocial behavior at the time of arrest predicted increased use of most health service use types over the next seven years (i.e. medicine prescriptions, tests for sexually transmitted infections, mental health service appointments, and out-of-home placements). All except prescription medication use remained significant when controlling for justice system processing and CU traits. Further, justice system processing added significantly to the prediction of medical service appointments. Whereas CU traits were associated with mental health service appointments and out-of-home placements, these did not remain significant when controlling for severity of antisocial behavior. These findings are consistent with prior research documenting the health care costs of antisocial behavior.

The Brief Adolescent Depression Screen: A Brief Screening Tool for Depression and Suicidal Behavior in Inpatient Adolescents.

Background: In clinical settings, there is significant need for brief, easily-administered assessment tools for adolescent depression that can be used by mental health clinicians from a variety of training backgrounds. Existing depression screening tools do not assess for duration and consistency of symptoms, two key indicators of pathological depression. Objective: The Brief Adolescent Depression Screen (BADS) was developed to screen for major and persistent depressive disorders in adolescents in order to meet the assessment needs in an inpatient setting, and the validity of this tool was tested. Method: The current study used a sample of 396 inpatient adolescents to assess the screening utility of the BADS for detecting whether the adolescent meets criteria for a depressive diagnosis according to a well-validated semi-structured interview, as well as detecting a positive history of suicidal behavior. Further, the screening utility of this measure was compared to the utility of an established depression rating scale. Results: Analyses first determined the duration of depressive symptoms on the BADS that optimally screened for the presence of Major Depressive Disorder and Persistent Depressive Disorder. Findings indicated that, using these optimal screening cut-offs, the BADS showed a strong screening utility, resulting in a sensitivity and specificity for identifying full depressive diagnoses and a positive history of suicidal behavior with similar or greater accuracy than an established rating scale. Conclusions: These findings provide initial evidence to suggest that the BADS may be a helpful screening tool for adolescent depressive disorders in inpatient settings.

Proactive and reactive aggression: Developmental trajectories and longitudinal associations with callous-unemotional traits, impulsivity, and internalizing emotions.

Research on proactive and reactive aggression has identified covariates unique to each function of aggression, but hypothesized correlates have often not been tested with consideration of developmental changes in or the overlap between the types of aggression. The present study examines the unique developmental trajectories of proactive and reactive aggression over adolescence and young adulthood and tests these trajectories' associations with key covariates: callous-unemotional (CU) traits, impulsivity, and internalizing emotions. In a sample of 1,211 justice-involved males (ages 15-22), quadratic growth models (i.e., intercepts, linear slopes, and quadratic slopes) of each type of aggression were regressed onto quadratic growth models of the covariates while controlling for the other type of aggression. After accounting for the level of reactive aggression, the level of proactive aggression was predicted by the level of CU traits. However, change in proactive aggression over time was not related to the change in any covariates. After accounting for proactive aggression, reactive aggression was predicted by impulsivity, both at the initial level and in change over time. Results support that proactive and reactive aggression are unique constructs with separate developmental trajectories and distinct covariates.

The bidirectional effects of antisocial behavior, anxiety, and trauma exposure: Implications for our understanding of the development of callous-unemotional traits.

The association of anxiety and trauma with antisocial behavior in children and adolescents has long been the focus of research, and more recently this area of research has become critical to theories of the development of callous-unemotional (CU) traits. Research suggests those with elevated CU traits and anxiety (i.e., secondary CU variant) seem to show more severe externalizing behaviors and are more likely to show histories of trauma, compared to those with elevated CU and low anxiety (i.e., primary CU variant). These findings have typically been interpreted as being indicative of distinct etiological pathways to the development of CU traits. We test an alternative explanation that the higher rates of anxiety and trauma exposure in some youth with elevated CU traits are largely a consequence of their higher levels of antisocial behavior. The current study recruited a sample of 1,216 justice-involved adolescents (Mage = 15.28, SD = 1.28) from three distinct regions of the United States, who were assessed at 6, 12, 18, 24, 30, 36, 48, and 60 months following their first arrest. Using random-intercept cross-lagged models, both antisocial behavior and CU traits predicted changes in future anxiety and CU traits predicted increases in future victimization. Further, using longitudinal parallel mediation models, antisocial and aggressive behavior largely accounted for the predictive association between CU traits and anxiety and CU traits and victimization. These results support a model in which anxiety and trauma histories may be a marker of the severity of antisocial behavior displayed by youth with elevated CU traits. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Developing Cutoff Scores for the Inventory of Callous-Unemotional Traits (ICU) in Justice-Involved and Community Samples.

Objective: The recent addition of the callous-unemotional (CU) traits specifier, "with Limited Prosocial Emotions (LPE)," to major classification systems has prompted the need for assessment tools that aid in the identification of elevations on these traits for diagnostic purposes. The goal of the current study was to use and evaluate multiple methods for establishing cutoff scores for the multi-informant questionnaire, the Inventory of Callous-Unemotional Traits (ICU).Method: The present study compared the clinical utility of various proposed cutoff methods and scores (i.e., empirically derived cutoffs using receiver operating characteristic (ROC), normative cutoffs, and rational scoring approximations of LPE criteria) in both a longitudinal sample of justice-involved male adolescents (N = 1,216; Mage = 15.29, SD = 1.29) and a cross-sectional sample of school children (N = 289; Mage = 11.47 years; SD = 2.26).Results: Methods resulted in a range of cutoff scores with substantial diagnostic overlap and validity. Specifically, they designated justice-involved adolescents at risk for later delinquency, aggression, and rearrests, and they designated school children more likely to be rated by parents and teacher as having conduct problems and rated by peers as being rejected and mean.Conclusions: The results lead to ranges of ICU scores that have support for their validity and can help to guide clinical decisions about children and adolescents who may be elevated on CU traits.

The Mood Disorder Assessment Schedule: Initial validation of a new measure for early identification of bipolar spectrum disorders in inpatient adolescents.

Due to the significant impairment associated with subthreshold bipolar symptomatology and the harmful effects of delayed diagnosis, there is a great need for diagnostic tools that can facilitate early identification of bipolar spectrum disorders. The Mood Disorder Assessment Schedule (MDAS) is a newly developed measure that focuses on autonomous changes in mood and energy, a key indicator of bipolar spectrum problems which is not included in current diagnostic tools for bipolar disorders. The current study tested the ability of the MDAS to identify individuals at risk for bipolar spectrum disorders. In a cross-sectional sample of 396 inpatient adolescents, the MDAS identified a group of individuals with several bipolar spectrum disorder (BSD) indicators, including greater manic and depressive symptoms, affective lability, suicidal behavior, adverse reactions to antidepressants, and a family history of bipolar disorder and suicidal behavior. When compared to a standard diagnostic interview for bipolar disorders (i.e., Kiddie Schedule for Affective Disorders and Schizophrenia [KSADS]), the MDAS yielded stronger clinical utility in its ability to identify individuals with BSD indicators. Therefore, the MDAS appears to be a promising diagnostic tool for identifying adolescents at risk for BSDs and may help facilitate earlier diagnosis and prevent harmful effects of improper treatment.

Inventory of Callous-Unemotional Traits (ICU) Factor Structure and Measurement Invariance in an Adolescent Multinational Sample.

OBJECTIVE: The Inventory of Callous-Unemotional Traits (ICU) is a widely used, comprehensive measure of callous-unemotional (CU) traits. While the ICU total score is used frequently in research, the scale's factor structure remains highly debated. Inconsistencies in past factor structure research appear to be largely due to the use of small non-representative samples and failure to control for method variance (i.e., item wording direction). METHOD: The current study used a multitrait-multimethod (MTMM) confirmatory factor analysis (CFA) approach that considers both trait and method variance to test the factor structure of a 22-item version of the self-report ICU in a multinational community sample of 4,683 adolescents (ages 11-17). RESULTS: Results showed that a hierarchical four-factor model (i.e., one overarching CU factor, four latent trait factors) that controlled for method variance (i.e., by allowing residuals from positively worded items to covary) provided the best fit (χ2 = 2797.307, df = 160, RMSEA=.059, CFI=.922, TLI=.888, SRMR=.045). CONCLUSIONS: After controlling for method variance, the best-fitting factor structure is consistent with how the ICU was developed and corresponds to the four symptoms of Limited Prosocial Emotions (LPE) specifier in the DSM-5 criteria for Conduct Disorder (CD). In addition, measurement invariance of this factor structure across age (i.e., younger versus older adolescents) and sex was supported. As a result, mean differences in ICU total score across age and sex can be interpreted as reflecting true variations in these traits. Further, we documented that boys generally scored higher than girls on the ICU, and this sex difference was larger in later adolescence.

Longitudinal associations of parental monitoring and delinquent peer affiliation: The potential influence of parental solicitation and monitoring rules.

INTRODUCTION: Poor parental monitoring has been theorized as a key risk factor for an adolescent's association with deviant peers. However, measurements of parental monitoring often only measure parental knowledge rather than parental monitoring actions, leaving the true longitudinal associations between parental monitoring and peer delinquency unclear. METHODS: The current sample consisted of 1095 male justice-involved adolescents (13-17 years old at baseline collected between 2011 and 2013) from across the United States who provided survey data every 6 months for 3 years. Longitudinal associations between parental monitoring constructs (i.e., parental solicitation and monitoring rules) and peer delinquency were tested using random intercept cross-lagged panel models to investigate both between-individual associations and within-individual bidirectional effects. RESULTS: Although parental monitoring and peer delinquency were negatively related at a between-individual level, very few within-individual directional effects were found. The few within-individual effects present indicated that parental solicitation predicted greater peer delinquency and peer delinquency predicted fewer parental monitoring rules over time. CONCLUSIONS: Current findings indicate that, while greater overall parental monitoring is associated with less peer delinquency, there is little evidence that changes in parental monitoring lead to reductions in peer delinquency over time. Results support previous findings suggesting parental monitoring should not be the sole target of intervention for reducing peer delinquency.

A Preliminary Analysis of Parent-Child Interaction Therapy Plus Natural Helper Support to Increase Treatment Access and Engagement for Low-Income Families of Color.

Disparities in care for low-income children of color call for innovative culturally and linguistically responsive solutions to better engage marginalized populations in evidence-based interventions. In partnership with a community organization, the addition of natural helper support as an adjunct to Parent-Child Interaction Therapy (PCIT+NH) was examined as a strategy to increase recruitment, engagement, and retention in PCIT for families historically unreached by a university-based clinic. Natural helpers provided home-based skills practice and support for forty-two families whose parents were more racially and linguistically diverse and had lower income and lower caregiver education than the typical population served by the same program (i.e., program population). Families who received PCIT+NH had comparable or higher rates of engagement and improvements in clinical outcomes (i.e., decreased child externalizing and internalizing behaviors, increased child compliance, decreased caregiver stress, increased caregiver parenting skills) relative to the program population. Furthermore, higher doses of natural helper support were associated with higher rates on most measures of treatment engagement (i.e., treatment completion, completion of the Child Directed Interaction phase of treatment, PCIT sessions, homework in the Parent Directed Interaction phase of treatment), with the exception of homework in the Child Directed Interaction phase of treatment and overall session attendance rate. Next steps for testing the treatment engagement and clinical outcome effects of the PCIT+NH model are discussed.

The associations of maternal warmth and hostility with prosocial and antisocial outcomes in justice-involved adolescents.

Parental warmth and hostility are two key dimensions of parenting for child development, but the differential effects of these parenting dimensions on child prosocial and antisocial development has not been adequately investigated. The current study hypothesized that parental warmth would be uniquely related to child callous-unemotional traits and prosocial behavior, whereas parental hostility would be uniquely related to child delinquency and aggression. These hypotheses were investigated in a diverse sample of 1,216 adolescent males (13 to 17 years old, 46% Latino, 37% Black) with justice-system involvement in the 5 years following their first arrest. Hybrid models estimated within- and between-individual associations over time, while controlling for the overlap between parental warmth and hostility and between child prosocial and antisocial outcomes. Results indicated that maternal warmth showed consistent associations with callous-unemotional traits and prosocial behavior over time, whereas maternal hostility showed consistent associations with delinquency and aggression over time. Further, the findings were similar across racial and ethnic groups. Implications for developmental models of antisocial behavior, particularly for those including the role of callous-unemotional traits, are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Longitudinal transactional relationships between caregiver and child mental health during the COVID-19 global pandemic.

BACKGROUND: Emerging work examining the psychological impact of COVID-19 on children and families suggests that the relationship between pandemic-related stress, child psychosocial functioning, and caregiver mental health are interrelated. However, much of this research is unidirectional and thus little is known about the bidirectional cascading effects children and caregivers may experience. The current study examined the transactional relationships between caregiver and child mental health over time during the COVID-19 pandemic. METHODS: Linguistically, racially, and ethnically diverse caregivers (N = 286) of young children completed measures of caregiver mental health, caregiver pandemic-related stress, and child mental health (i.e., externalizing, internalizing, prosocial behavior) across three time points in the spring of 2020. RESULTS: Using autoregressive cross-lagged analyses, impaired caregiver mental health at Time 1 (April 2020) predicted increased caregiver pandemic-related stress at Time 2 (May 2020). Caregiver pandemic-related stress at Time 1 predicted increased child internalizing symptoms at Time 2 which, in turn, predicted increased caregiver pandemic-related stress at Time 3 (July 2020). Lastly, impaired caregiver mental health at Time 2 (May 2020) predicted increased child externalizing symptoms at Time 3 (July 2020). CONCLUSIONS: Assessing transactional relationships between child and caregiver mental health during the COVID-19 pandemic is important to inform models of risk and resilience. Interventions at the level of the caregiver, the child, and/or the family should be considered as a way to interrupt potential negative developmental cascades.

Do callous-unemotional traits moderate the effects of the juvenile justice system on later offending behavior?

BACKGROUND: Research suggests that callous-unemotional (CU) traits, a recent addition to psychiatric classification of serious conduct problems, may moderate the influence of a number of contextual factors (e.g., parenting, deviant peer influence) on an adolescent's adjustment. The current study sought to replicate past research showing that formal processing through the juvenile justice system increases recidivism and tested the novel hypothesis that CU traits would moderate the relationship between processing decision and future antisocial behavior. METHODS: A diverse sample of first-time male offenders (N = 1,216; M age = 15.12, SD = 1.29) in three regions of the United States was assessed within 6 weeks of their first arrest and then at 6-month intervals for 36 months. RESULTS: Compared to those who were informally processed (i.e., diverted), adolescents formally processed through the court were at a higher risk of self-reported offending and rearrests as measured by official records, after controlling for preexisting risk factors. However, baseline CU traits moderated this association such that those with high CU traits reported offending at high rates across the subsequent three years regardless of how the juvenile justice system processed their case. CONCLUSIONS: CU traits are important to psychiatric classification for designating a subgroup of antisocial youth who may respond differently to contextual influences, including being less susceptible to the negative effects of juvenile justice system involvement. The public health significance of this moderation is significant by suggesting that previous estimates of the harmful impact of formal processing by the juvenile justice system may underestimate its impact, given that the majority of arrested adolescents have normative levels of CU traits.

Psychometric Properties of a Semistructured Interview to Assess Limited Prosocial Emotions.

Callous-unemotional (CU) traits have recently been added to the diagnostic criteria of Conduct Disorder in the Diagnostic and Statistical Manual of Mental Disorders-Fifth edition and of conduct-dissocial and oppositional defiant disorders in the International Classification of Disease-Eleventh edition as the limited prosocial emotions specifier. This change necessitates the assessment of these traits with validated measures in both research and clinical contexts. The current study sought to validate a semi-structured diagnostic interview method, the Michigan Limited Prosocial Emotion Addendum (M-LPE) to the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version, of assessing CU traits based on a recently developed clinician rating system (Clinical Assessment of Prosocial Emotions, Version 1.1) in a sample of at-risk youth. Results supported the interrater reliability of the M-LPE with moderate agreement and high reliability between raters. The M-LPE demonstrated convergent and incremental validity with CU traits and various measures of antisocial behavior. The results provide preliminary evidence for the use of a semi-structured interview assessment of CU traits in research contexts and build the foundation for further validation.

Reduced Multivoxel Pattern Similarity of Vicarious Neural Pain Responses in Psychopathy.

Psychopathy is a personality construct characterized by interpersonal callousness, boldness, and disinhibition, traits that vary continuously across the population and are linked to impaired empathic responding to others' distress and suffering. Following suggestions that empathy reflects neural self-other mapping-for example, the similarity of neural responses to experienced and observed pain, measurable at the voxel level-we used a multivoxel approach to assess associations between psychopathy and empathic neural responses to pain. During fMRI scanning, 21 community-recruited participants varying in psychopathy experienced painful pressure stimulation and watched a live video of a stranger undergoing the same stimulation. As total psychopathy, coldheartedness, and self-centered impulsivity increased, multivoxel similarity of vicarious and experienced pain in the left anterior insula decreased, effects that were not observed following an empathy prompt. Our data provide preliminary evidence that psychopathy is characterized by disrupted spontaneous empathic representations of others' pain that may be reduced by instructions to empathize.

Callous-Unemotional Traits and Risk of Gun Carrying and Use During Crime.

OBJECTIVE: With the addition of the "with limited prosocial emotions" specifier within the diagnosis of conduct disorder (DSM-5) and of conduct-dissocial disorder (ICD-11) to designate those with elevated callous-unemotional traits, the authors examined the role that callous-unemotional traits play in the risk for gun carrying and gun use during a crime in a sample at high risk for gun violence. METHODS: Male juvenile offenders (N=1,215) from three regions of the United States were assessed after their first arrest and then reassessed every 6 months for 36 months and again at 48 months. Callous-unemotional traits and peer gun carrying and ownership were measured via self-report after the first arrest (i.e., baseline). Gun carrying and use of a gun during a crime were self-reported at all follow-up points. RESULTS: Callous-unemotional traits at baseline increased the frequency of gun carrying and the likelihood of using a gun during a crime across the subsequent 4 years after accounting for other risk factors. Furthermore, callous-unemotional traits moderated the relationship between peer gun carrying and ownership and participant gun carrying, such that only participants low on callous-unemotional traits demonstrated increased gun carrying as a function of their peers' gun carrying and ownership. CONCLUSIONS: This study demonstrates the importance of considering callous-unemotional traits in gun violence research both because callous-unemotional traits increase gun carrying and use in adolescents and because the traits may moderate other key risk factors. Notably, the influence of peer gun carrying and ownership may have been underestimated in past research for the majority of adolescents by not considering the moderating influence of callous-unemotional traits.

Activation in bed nucleus of the stria terminalis (BNST) corresponds to everyday helping.

Everyday prosociality includes helping behaviors such as holding doors or giving directions that are spontaneous and low-cost and are performed frequently by the average person. Such behaviors promote a wide array of positive outcomes that include increased well-being, trust, and social capital, but the cognitive and neural mechanisms that support these behaviors are not yet well understood. Whereas costly altruistic responding to others' distress is associated with elevated reactivity in the amygdala, we hypothesized that everyday prosociality would be more closely associated with activation in the bed nucleus of the stria terminalis (BNST), a region of the extended amygdala known for its roles in maintaining vigilance for relevant socio-affective environmental cues and in supporting parental care. One previous study of the neural correlates of everyday prosociality highlighted a functional cluster identified as the septal area but which overlapped with established coordinates of BNST. We used an anatomical mask of BNST (Torrisi et al., 2015) to evaluate the association of BNST activation and daily helping in a sample of 25 adults recruited from the community as well as 23 adults who had engaged in acts of extraordinary altruism. Results found that activation in left BNST during an empathy task predicted everyday helping over a subsequent 14-day period in both samples. BNST activation most strongly predicted helping strangers and proactive helping. We conclude that beyond facilitating care for offspring, activation in BNST may provide a basis for the motivation to engage in a broad array of everyday helping behaviors.

Does self-report of aggression after first arrest predict future offending and do the forms and functions of aggression matter?

The current study tested whether a self-report measure of aggression (i.e., the Peer Conflict Scale; PCS) would predict later delinquency, after controlling for other risk factors, and tested whether the different forms and functions of aggression contributed independently to this prediction. Self-report of aggression was assessed at the time of first arrest, and both self-report of delinquency and official arrests were assessed at 5 different time points over a 30-month follow-up period in a sample of male adolescent offenders (N = 1,216; Mage = 15.12, SD = 1.29 years) arrested in 3 regions (i.e., western, southern, northeast) of the United States. Aggression predicted both later total and later violent self-reported delinquency (odds ratio [OR] = 1.02, 95% confidence interval [CI: 1.01, 1.02]), even after controlling for youths' self-reported lifetime history of delinquent acts and callous-unemotional (CU) traits (i.e., Inventory of Callous-Unemotional Traits) collected at initial arrest. Further, only self-reported aggression (but not lifetime delinquency and CU traits) contributed independently (OR = 1.02, 95% CI [1.00, 1.03]) to the prediction of arrests for violent offenses. Finally, the predictive utility of aggression was largely accounted for by physical and reactive aggression, with limited incremental prediction provided by relational and proactive aggression. These findings support the potential utility of self-reports of aggression, such as the PCS, when assessing risk for future violence. Findings also suggest that the utility of these self-reports of aggression cannot be solely accounted for by other risk factors often included in typical risk assessment tools. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Increased similarity of neural responses to experienced and empathic distress in costly altruism.

Empathy-affective resonance with others' sensory or emotional experiences-is hypothesized to be an important precursor to altruism. However, it is not known whether real-world altruists' heightened empathy reflects true self-other mapping of multi-voxel neural response patterns. We investigated this relationship in adults who had engaged in extraordinarily costly real-world altruism: donating a kidney to a stranger. Altruists and controls completed fMRI testing while anticipating and experiencing pain, and watching as a stranger anticipated and experienced pain. Machine learning classifiers tested for shared representation between experienced and observed distress. Altruists exhibited more similar representations of experienced and observed fearful anticipation spontaneously and following an empathy prompt in anterior insula and anterior/middle cingulate cortex, respectively, suggesting heightened empathic proclivities and abilities for fear. During pain epochs, altruists were distinguished by spontaneous empathic responses in anterior insula, anterior/mid-cingulate cortex and supplementary motor area, but showed no difference from controls after the empathy prompt. These findings (1) link shared multi-voxel representations of the distress of self and others to real-world costly altruism, (2) reinforce distinctions between empathy for sensory states like pain and anticipatory affective states like fear, and (3) highlight the importance of differentiating between the proclivity and ability to empathize.

Callous and uncaring traits are associated with reductions in amygdala volume among youths with varying levels of conduct problems.

BACKGROUND: The emergence of callous unemotional (CU) traits, and associated externalizing behaviors, is believed to reflect underlying dysfunction in the amygdala. Studies of adults with CU traits or psychopathy have linked characteristic patterns of amygdala dysfunction to reduced amygdala volume, but studies in youths have not thus far found evidence of similar amygdala volume reductions. The current study examined the association between CU traits and amygdala volume by modeling CU traits and externalizing behavior as independent continuous variables, and explored the relative contributions of callous, uncaring, and unemotional traits. METHODS: CU traits and externalizing behavior problems were assessed in 148 youths using the Inventory of Callous Unemotional Traits (ICU) and the Child Behavior Checklist (CBCL). For a subset of participants (n = 93), high-resolution T1-weighted images were collected and volume estimates for the amygdala were extracted. RESULTS: Analyses revealed that CU traits were associated with increased externalizing behaviors and decreased bilateral amygdala volume. These results were driven by the callous and uncaring sub-factors of CU traits, with unemotional traits unrelated to either externalizing behaviors or amygdala volume. Results persisted after accounting for covariation between CU traits and externalizing behaviors. Bootstrap mediation analyses indicated that CU traits mediated the relationship between reduced amygdala volume and externalizing severity. CONCLUSIONS: These findings provide evidence that callous-uncaring traits account for reduced amygdala volume among youths with conduct problems. These findings provide a framework for further investigation of abnormal amygdala development as a key causal pathway for the development of callous-uncaring traits and conduct problems.

Extraordinary Altruists Exhibit Enhanced Self-Other Overlap in Neural Responses to Distress.

Shared neural representations during experienced and observed distress are hypothesized to reflect empathic neural simulation, which may support altruism. But the correspondence between real-world altruism and shared neural representations has not been directly tested, and empathy's role in promoting altruism toward strangers has been questioned. Here, we show that individuals who have performed costly altruism (donating a kidney to a stranger; n = 25) exhibit greater self-other overlap than matched control participants ( n = 27) in neural representations of pain and threat (fearful anticipation) in anterior insula (AI) during an empathic-pain paradigm. Altruists exhibited greater self-other correspondence in pain-related activation in left AI, highlighting that group-level overlap was supported by individual-level associations between empathic pain and firsthand pain. Altruists exhibited enhanced functional coupling of left AI with left midinsula during empathic pain and threat. Results show that heightened neural instantiations of empathy correspond to real-world altruism and highlight limitations of self-report.