Working with children with conduct problems and their families

28th November 201310.30am-12.00pm AEDT

PRESENTERS:Professor Mark R DaddsDirector of the Child Behaviour Research Clinic, Professor of Psychology, University of New South Wales

Dr Sophie HavighurstSenior Lecturer and Clinical Psychologist University of Melbourne

Facilitator: Bella Saunders, Senior Psychologist APS

Love and eye contact in the aetiology and treatment of early-onset conduct problems.

Mark R Dadds

Why study conduct problems?problems?

Conduct disorders & operant/attachment theory

My experience of 20 years of Child & Family CBT

• -Triple P• -Move from single techniques to “big” therapies• -Manuals and commercial dissemination• -Everything works at about 50%• -Can we learn from our failures?

Aims

Design assessments and interventions that are sensitive to child–specific ‘causal’ variables.

Heterogeneity in conduct problem childrenHot CD – emotional/anxious

- high susceptability to environments- “normal aggression”.

Cold CD- callous/unemotional (measured through parent-teacher report)

- low susceptability to environment- “abnormal aggression.”

Proband Co-twin Transformed co-twin mean (SD) mean (SD) mean h2g c2g

a) Extreme antisocial behaviour in children without psychopathic tendencies (N ¼ 210)

MZ twins 2.02 (.62) 1.29 (1.24) .64 .30 (-.10–.70) .34 (-.40–1.08) DZ twins 2.15 (.88) 1.05 (1.66) .49

b) Extreme callous-unemotional MZ twins (N = 612) MZ twins 1.79 (.56) 1.30 (.96) .73 .67 (.47–.87) .06 (-.23–.35) DZ twins 1.80 (.57) .71 (1.05) .39

c) Extreme antisocial behaviour in children with psychopathic tendencies (N = 234) MZ twins 2.82 (1.13) 2.15 (1.52) .76 .81 (.50–1.12) ) .05 (.00–.72) DZ twins 2.81 (1.26) 1.00 (1.72) .36

   

Viding, Blair, Moffitt & Plomin (2005)

Attention in emotion processing Increasing evidence that various forms of psychopathology

are associated with deficits in processing emotions

Relevant genotypes differently associated with amygdala activity to threatening faces

Psychopathy associated with specific deficits in fear recognition and low amygdala response

Anxiety/depression/hot aggression associated with increased fear recognition and high amygdala response

Correlations between CU, Antisocial and accuracy of emotion recognition

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Emotion

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Antisocial

CU traitsDimension

Dadds MR et al (2006). Look at the eyes: Fear recognition in child psychopathy. British Journal of Psychiatry, 189, 180-181.

Munoz et al (2009) Journal of the American Academy of Child & Adolescent Psychiatry, 48, 5 554-562

Blair et al (2002) – vocal cues.

Language of the eyes(super-stimuli)

• Amygdala and attention, social gaze

• Ralph Adolph’s work

Fear stimulus

Aversive threat Information about environment from following other’s gaze

Observer

Idea 1: Fear perception and theory of mind

http://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=An%20external%20file%20that%20holds%20a%20picture%2C%20illustration%2C%20etc.%0AObject%20name%20is%20nihms73540f2.jpg%20%5BObject%20name%20is%20nihms73540f2.jpg%5D&p=PMC3&id=2580742_nihms73540f2.jpg

LowHigh

CU category

Free Eyes MouthGaze

1.0

1.3

1.5

1.8

2.0Mean accuracy of facial fear recognition for boys high and low on CU traits under three Gaze conditions: no instruction, instruction to focus on eyes, instructed to focus on mouth. Significant interaction between Gaze and CU category, F(2,55) = 5.149, p =.009. Error bars represent standard errors of the mean.

Eye Gaze Hotspots

“Cold’ conduct problems

Healthy boys Hi CU boys

Dadds et al. (2008) J Amer Acad Child Adolesc Psych.

So?

Does it happen in the real world?

With attachment figures?

Copyright restrictions may apply.

Jones, W. et al. Arch Gen Psychiatry 2008;65:946-954.

Example visual scan-paths and fixation time summaries for 3 toddlers watching the same video of an actress playing the role of a caregiver

Study 1:

But.........

•No control group•Age spread•Expensive coding•Inappropriate tasks

•And….WARMTH!

Study 2:

Method

• Participants

• N = 24 children between 3 and 8 years of age;

• n = 12 with Oppositional Defiant Disorder (ODD)

• n = 12 comparison group.

• The LOVE interaction

Healthy dyad:

The Eye-Love-You Game

The Eye-Love-You Game

Interpretations

1. Low eye contact is just another marker of low empathy

2. Low eye contact drives the development of low empathy and low susceptibility to parenting

3. Arguments:1. Shaw et al (2005) – early versus late amygdala damage2. The primacy of parent-child eye contact3. Newman et al. And Dadds et al. on attentional manipulations

OXYTOCIN

Oxytocin .........

“who’s important to me, who I’d die for, who I’m pair-bonded with, who will take care of me,”

(Thomas Insel)

Oxytocin and vasopressin levels after interaction with mothers

Reading the Mind in the Eyes Test jealous panicked

arrogant hateful

Guastella A, Dadds MR, & Mitchell PB. (2009) Oxytocin increases gaze to the eye-region of human faces. Biological Psychiatry.

Conclusions:

• CU traits are associated with an impairment in attention to emotional cues:

These cues usually function as “super-stimuli” through development, provoking and consolidating important neural system that scaffold the development of affective contagion through to empathic concern;

An error that in the system driving attention to these stimuli could lead to cascading errors across the development of empathic concern;

While we cannot exclude environmental input, this impairment in the attachment system - genetic and epigenetic variations in the oxytocin receptor system.

OXT (/SERT) systems

Contagious affect

Attention to emotional stimuli

Pubertal transition

Moral conscience

Quality of parenting - reciprocated love

Implications for future treatments

Specific parenting strategies need to be refined in terms of specific emotional attention proclivities of the child. e.g.

Eye contact with “hot” versus “cold problem children Behavioural experiments with eye contact (love and

attachment)

Emotion attention/recognition training

Biobehavioural manipulations of the OXT system

Dadds, Cauchi, Wimalaweera, Hawes, & Brennan. Psychiatry Research (in press).

Thanks to

Sydney: David Hawes, John Brennan, Caroline Moul, Subodha Wimmalaweera, Dave Pasalich, Jasmin Jambrak, Avril Cauchi

London: Stephen Scott, Jen Allen, Bonamy Oliver, Nathan Faulkner, Kat Legge, Caroline Moul, Matt Woolgar

Thank YOU!

Written by

Sophie Havighurst

and Ann Harley

Working with Children with Conduct Problems: The Tuning in to Kids program

Dr Sophie Havighurst

www.tuningintokids.org.au

Overview of Tuning in to Kids

Tuning in to Kids (TIK) is an evidence- based program that helps parents

teach their children about emotions while building a close and supportive

relationship.

What is the TIK program?• Six session, parenting group program• Focus on emotions in parents and children• Parents become aware of their child’s

emotions and coach their child in being able to understand and regulate emotions

• Parents become aware of and regulate their own emotions when parenting

• In children - prevents problems from developing, or reduces problems that exist

• Can be used in individual therapy

Theoretical Basis

•Based on the theory about the role of parent emotion socialization practices in shaping children’s emotional and behavioural competence.

•Targets emotional communication in parent-child relationships

•Draws on aspects of social learning theory, attachment theory, mindfulness and emotion coaching

Emotion Coaching To emotion coach your child you:• Become aware of their emotion, especially if it is of a

lower intensity (such as disappointment or frustration)

• View their emotion as an opportunity for intimacy and teaching

• Communicate your understanding and acceptance of the emotion – empathy

• Help them use words to describe what they feel• If necessary, help them to solve problems. You may

also communicate that all wishes and feelings are acceptable, but some behaviours are not.

Adapted from Gottman, J. M. & DeClair, J. (1997). The Heart of Parenting: Raising an Emotionally Intelligent Child. New York: Simon & Schuster.

TIK Theoretical Model

Parenting: •Attitudes/beliefs•Emotion coaching•Mindfulness•Responsiveness

Child Emotion Competence•Emotionality•Emotion Regulation•Emotion Knowledge

Child Factors•Temperament•Neurophysiology•Gender•Cognition/language

Social/Cultural Factors

Child Outcomes•Behaviour•Social Skills•Academic •Health

Family of Origin

experience with

emotion

Parent Functioning •Emotion awareness•Emotion wellbeingFamily Functioning:•Emotion climate

Parent Meta-

Emotion Philosophy

Tuning in to Kids

Program

Why TIK with children with behaviour problems?

• Diverse approaches are needed• Strategies for increasing attachment and building

close connections between parents and children• Assist parents to shift from automatic patterns in

parenting• Put developmental theories about emotional

intelligence/competence into action• Understand the emotional needs that lie behind

challenging behaviours• A complement for behavioural techniques (such as

Triple P) or a different approach altogether.

TIK Research Evidence

Research on TIK and program variantsTuning in to Toddlers• Pilot study (2010-2012) - MA student Michelle LauwTIK Preschool Research Studies:• pilot study (2000-2002)• RCT community efficacy trial (2006-2009)• Case studies with anxious children (2008-2010) – PhD student Galit Hasen• RCT clinical efficacy trial (2006-2009)• RCT community effectiveness trial (2010-2011)• DADS TIK pilot study (2011) • DADS TIK RCT efficacy trial – (2012-2014)TIK School Aged Research Studies• RCT with conduct problem children - CASEA (2008-2013) - PhD student Melissa Duncombe • RCT clinical sample children with chronic illness (2012-2014) - PhD student Wai Wai Yang• Trauma-focused pilot study (2009-2013) - with Australian Childhood FoundationTuning in to Teens – Pre-adolescents and adolescents• TINT (pre-adolescent) pilot study (2007)• TINT (pre-adolescent) efficacy trial – RCT (2009-2012) – PhD student Christiane Kehoe• TINT (pre-adolescent) qualitative study (2009-2012) – MA for Ann Harley• TINT (adolescent) efficacy trial – RCT (2013 – 2017)

Research Publications• Duncombe, M. E., Havighurst, S. S., Holland, K. A., Frankling, E. J., Kehoe, C., & Stargatt, R.

(under review). A randomized controlled comparison of an emotion- and behavior-focused group parenting program for children at risk for conduct disorder. Journal of Child and Adolescent Psychology.

• Havighurst, S. S., Harley, A., & Prior, M. (2004). Building preschool children's emotional competence: A parenting program. Early Education and Development, 15(4), 423-448.

• Havighurst, S. S., Wilson, K. R., Harley, A. E., & Prior, M. R. (2009). Tuning in to kids: An emotion-focused parenting program - initial findings from a community trial. Journal of Community Psychology, 37(8), 1008-1023.

• Havighurst, S. S., Wilson, K. R., Harley, A. E., Prior, M. R., & Kehoe, C. (2010). Tuning in to Kids: Improving emotion socialization practices in parents of preschool children – findings from a community trial. Journal of Child Psychology and Psychiatry, 51(12), 1342-1350.

• Havighurst, S. S., Wilson, K. R., Harley, A. E., Kehoe, C., Efron, D., & Prior, M. R. (2013). “Tuning in to Kids”: Reducing young children’s behavior problems using an emotion coaching parenting program. Child Psychiatry & Human Development, 44(2), 247-264.

• Havighurst, S. S., & Harley, A. E. (2013). Tuning in to Kids: Emotion coaching for early learning staff. Belonging: Early Years Journal, 2(1), 22-25.

• Havighurst, S. S., Kehoe, C. E., Harley, A. E., & Wilson, K. R. (in Press). Tuning in to Kids: An emotion focused parenting intervention for children with disruptive behaviour problems. Child & Adolescent Mental Health (Occasional Paper).

Research Publications continued• Havighurst, S.S., Duncombe, M., Frankling, E., Holland, K., Kehoe, C., & Stargatt, R. (under

review). An Emotion-Focused Early Intervention for Children with Emerging Conduct Problems. Journal of Abnormal Child Psychology.

• Kehoe, C. E., Havighurst, S. S., & Harley, A. E. (Early View). Tuning in to Teens: Improving parent emotion socialization to reduce youth internalizing difficulties. Social Development. doi: 10.1111/sode.12060

• Kehoe, C. E., Havighurst, S. S., & Harley, A. E. (under review). Somatic complaints in early adolescence: The role of parents' emotion socialization. Journal of Early Adolescence.

• Lauw, M. S. M., Havighurst, S. S., Wilson, K., Harley, A. E., & Northam, E. A. (in press). Improving parenting of toddlers’ emotions using an emotion coaching parenting program: A pilot study of tuning in to toddlers. Journal of Community Psychology.

• Murphy, J. L., & Havighurst, S. S. (under review). Trauma-focused “Tuning in to Kids”: A pilot study. Journal of Traumatic Stress.

• Wilson, K. R., Havighurst, S. S., & Harley, A. E. (2012). Tuning in to Kids: An effectiveness trial of a parenting program targeting emotion socialization of preschoolers. Journal of Family Psychology, 26(1), 56-65.

• Wilson, K., Havighurst, S. S., & Harley, A. E. (in press). Dads Tuning in to Kids: Piloting a new parenting program targeting fathers’ emotion coaching skills. Journal of Community Psychology.

Research trials of TIK with children with behaviour problems

• Clinical/sub-clinical trials– Preschool RCT with children with clinical presentations to

RCH with behaviour problems (RCH trial)– School-aged RCT with 5-9 yr olds with emerging conduct

disorder (CASEA trial)– Pilot study of Children who have experienced complex

trauma – (Australian Childhood Foundation trial).• Community RCT’s

– Preschool efficacy trial– Pre-adolescent efficacy trial.

The use of an emotion coaching parenting program as part of an early intervention for children with emerging conduct disorder

Child and Adolescent Mental Health Service

Research Method

• Prep-Grade 3 children from 48 schools• Randomized by school into two intervention conditions

(Tuning in to Kids or Triple P) or 12 month waitlist control• Assessment baseline and 10 month follow-up• Parent/teacher Questionnaires plus direct child assessment• School-wide universal intervention, parent and child groups

and referral on as needed

Participant Demographics

Variable Intervention Control

n 91 113

Child Gender(% Male) 68 (74.7) 83 (73.5)

Age in years M (SD) 7.1 (1.3) 7.0 (.9)

Pro-Rated Full Scale IQ M (SD) 92.5 (15.1) 90.3 (14.5)

Eyberg Child Behavior Inventory

Intensity Score - M (SD)144.93 (40.09) 140.47 (40.09)

Gross Annual Income (% Low Income <$60,000)

57 (62.6%) 49 (43.4%)

MeasuresMeasure Source Construct

Maternal Emotional Style Questionnaire (Lagacé-Séguin & Coplan, 2005)

• Parent report • Parent emotion dismissing• Parent Emotion coaching • Parent Empathy

Emotion Regulation Checklist Shields & Cicchetti, 1997

• Parent report • Child Emotion regulation• Child Lability/negativity

Eyberg Child Behavior Inventory (Eyberg & Pincus, 1999)

• Parent report • Child Oppositional defiant disorder

• Child Conduct disorder

Strengths and Difficulties Questionnaire (Goodman, 1997)

• Teacher report • Child Behavior problems

Metcalf Behavioural Checklist • Teacher report • Child responsiveness• Child confidence

Kusche Affective Inventory (Kusche, Greenberg, & Beilke, 1988).

• Direct child assessment

• Child Emotion identification• Child Emotion understanding

WISC-IV/WPPSI-lll • Direct child assessment

• Child IQ functioning

Parent report - Oppositional Defiant and Conduct Problems

Significant interaction Condition*Time:β = -7.62, SE = .2.95, t(150.96) = -2.58, p = .011, 95%CI: -13.45, -1.80, d = .37

Significant interaction Condition*Time:β = -4.84, SE = 1.91, t(156.20) = -2.53, p = .012, 95%CI: -8.61, -1.07, d = .37

Conduct Problems

Teacher report - Behavior Difficulties

Significant interaction Condition*Time:β = -3.01, SE = 1.01,t(176.64) = -2.98, p = .003, 95%CI: -5.01, -1.02 d = .41

Direct Assessment Emotion Identification and Understanding

Significant main effect for time only:

β = 2.37, SE = .48, t(180.4) = 4.91,

p = .000, 95%CI: 3.32,1.42

Significant interaction Condition*Time:β = 2.23, SE = .83, t(181.42) = 2.69, p = .008, 95%CI: .59, 3.86, d = .50

Emotion Identification Emotion Understanding

Conclusions • The combination of a child social-emotional program,

a universal/school program, and emotion-focused parenting program, Tuning in to Kids, has had a significant and positive impact on children’s emotional competence and behavior.

• Changes found across home, school and direct assessment of the child

• Parenting significantly improved with reduced emotion dismissiveness and increased empathy

• The child and parent programs were complementary

Key TIK strategies for working with parents who have a child with behaviour problems

Key strategies for parents• Attend to low intensity emotions in contrast to use of planned

ignoring• Emotion coach the feelings behind anger rather than just focus

on the angry behaviours• Assist parents to see the difference between angry emotions

and behaviour• Encourage acceptance of emotions and differentiate some

behaviours are acceptable and some are not • Use of limit setting and family rules• Examine parents own emotional reactions to children’s

emotions (especially anger) and explore their family of origin experience with emotions

• Help parents develop skills in their own emotion awareness and regulation as well as self-care.

Key strategies continued…• Contrast emotion dismissing with emotion coaching in role plays

(watching dvd, using scripts, or in-session role play)• When children are angry, parents stay close to their child

(providing they are not very angry themselves) rather than separating them or using time out

• Emotion coaching may be used a little during highly emotional times (name the emotion) but especially used afterwards when emotions have reduced

• Links are made to neurobiology where prefrontal cortex is less functional when very emotional – parents are encouraged to use less talk at these times

• Teach a range of emotion regulation skills such as, slow breathing (for anger or anxiety), progressive muscle relaxation, turtle technique or variants, letting off steam, calming strategies.

Case Study example

TIK Training and Dissemination

TIK Training and Dissemination

• 2 day training workshop for facilitators with ongoing supervision to assist with delivery

• In-service training options provided and tailored to the service and skill level of staff

• Use of a structured manual• Since 2007 over 2500 professionals

trained• Translations of parent handouts into

Somali, Arabic, Vietnamese, Amharic, Cantonese.

Adaptations and use of TIK

• CAMHS and CASEA• Australian Childhood Foundation – trauma • Inpatient CAMHS • Drug and Alcohol Rehabilitation• Prisons• Educational settings including teacher education• Indigenous • Multi-cultural • Young single mothers playgroups • Kinship carers, grandparents and foster carers.

Acknowledgements• Program Authors: Sophie Havighurst and Ann Harley• Research Team Contributors:

Sophie Havighurst, Katherine Wilson, Christiane Kehoe, Margot Prior, Ann Sanson, Daryl Efron, Ann Harley, Elizabeth Pizarro, Galit Hasen, Rebecca Banks, Emily Incledon, Angeline Ho, Lara Silkoff, Melissa Bourchier, Michelle Lauw, Melissa Duncombe, Austin and Bendigo CASEA teams, Robyn Stargatt

• Research Collaborators:– Mindful, Department of Psychiatry, University of Melbourne– ParentsLink at MacKillop Family Services– Centre for Community Child Health, RCH– Dianella Community Health– Knox City Council– Australian Childhood Foundation– CASEA - Bendigo and Austin CAMHS

• Research Funded by:– Australian Rotary Health– Financial Markets Foundation for Children– William Buckland Foundation– University of Melbourne– Helen Macpherson Smith Trust

Contact Details• Email address - Sophie Havighurst

sophie.h@unimelb.edu.au

• For Training Enquiries see our website www.tuningintokids.org.au or contact Ann Harley, Training Manager, 03 9371-0210 aeharley@unimelb.edu.au

QUESTIONS & ANSWERS

REMINDERS• Contact The ATAPS CMHS Clinical Support Service. Phone on

1800 031 185 or email clinicalsupport@psychology.org.au

• Next Wednesday webinar on working with young children and a further series in 2014

• A recording of the webinar will be available on the APS website shortly. See http://www.psychology.org.au/ATAPS/networking_CMHS/

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