here - Australian Psychological Society

Report
Working with children with conduct
problems and their families
28th November 2013
10.30am-12.00pm AEDT
PRESENTERS:
Professor Mark R Dadds
Director of the Child Behaviour Research Clinic,
Professor of Psychology,
University of New South Wales
Dr Sophie Havighurst
Senior 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
problems?
Why study conduct problems?
Conduct disorders &
operant/attachment theory
My experience of 20 years of Child & Family
CBT
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-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
children
Hot CD – emotional/anxious
- high susceptability to environments
- “normal aggression”.
Cold CD- callous/unemotional (measured through parent-teacher
report)
- low susceptability to environment
- “abnormal aggression.”
Viding, Blair, Moffitt & Plomin (2005)
Proband
m ean (SD )
C o-tw in
T ransform ed co-tw in
m ean (SD )
m ean
2
2
hg
cg
a) E xtrem e antisocial behaviour in children w ithout psychopathic tendencies (N ¼ 210)
M Z tw ins 2.02 (.62)
D Z tw ins 2.15 (.88)
1.29 (1.24)
1.05 (1.66)
.64
.49
.30 (-.10–.70)
.34 (-.40–1.08)
.73
.39
.67 (.47–.87)
.06 (-.23–.35)
b) E xtrem e callous-unem otional M Z tw ins (N = 612)
M Z tw ins 1.79 (.56)
D Z tw ins 1.80 (.57)
1.30 (.96)
.71 (1.05)
c) E xtrem e antisocial behaviour in children w ith psychopathic tendencies (N = 234)
M Z tw ins 2.82 (1.13)
D Z tw ins 2.81 (1.26)
2.15 (1.52)
1.00 (1.72)
.76
.36
.81 (.50–1.12) ) .05 (.00–.72)
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
Dimension
CU traits
Antisocial
Partial Correlation
0.20
0.00
-0.20
-0.40
-0.60
happy
sad
angry
fear
disgust
neutral
Emotion
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
Idea 1: Fear perception and theory of mind
Fear
stimulus
Aversive threat
Information about
environment from
following other’s gaze
Observer
Mean 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.
2.0

CU category
Low

A cc ur ac y
1.8

1.5

High

1.3

1.0
Free
Eyes
Gaze
Mouth
Eye Gaze
Hotspots
Healthy boys
“Cold’ conduct
problems
Dadds et al. (2008) J Amer Acad Child Adolesc Psych.
Hi CU boys
So?
Does it happen in the real world?
With attachment figures?
Example visual scan-paths and fixation time summaries for 3 toddlers watching the same video of an
actress playing the role of a caregiver
Jones, W. et al. Arch Gen Psychiatry 2008;65:946-954.
Copyright restrictions may apply.
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
The Eye-Love-You Game
Healthy
dyad:
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 damage
2. The primacy of parent-child eye contact
3. 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 pairbonded 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
arrogant
panicked
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
Attention to emotional
stimuli
Quality of parenting reciprocated love
Pubertal transition
Contagious affect
Moral conscience
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!
Working with Children with Conduct Problems:
The Tuning in to Kids program
Dr Sophie Havighurst
Written by
Sophie Havighurst
and Ann Harley
www.tuningintokids.org.au
Overview of
Tuning in to Kids
Tuning in to Kids (TIK) is an evidencebased program that helps parents
teach their children about emotions
while building a close and supportive
relationship.
What is the TIK program?
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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 parentchild 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
Tuning in to
Kids
Program
Social/Cultural
Factors
Family of
Origin
experience
with
emotion
Parent
MetaEmotion
Philosophy
Child Factors
•Temperament
•Neurophysiology
•Gender
•Cognition/language
Parent Functioning
•Emotion awareness
•Emotion wellbeing
Family Functioning:
•Emotion climate
Child Emotion Competence
•Emotionality
•Emotion Regulation
•Emotion Knowledge
Parenting:
•Attitudes/beliefs
•Emotion coaching
•Mindfulness
•Responsiveness
Child
Outcomes
•Behaviour
•Social Skills
•Academic
•Health
Why TIK with children with
behaviour problems?
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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 variants
Tuning in to Toddlers
• Pilot study (2010-2012) - MA student Michelle Lauw
TIK 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 Foundation
Tuning 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
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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
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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
n
Child Gender
(% Male)
Age in years
M (SD)
Pro-Rated Full Scale IQ
M (SD)
Eyberg Child Behavior Inventory
Intensity Score - M (SD)
Gross Annual Income
(% Low Income <$60,000)
Intervention
Control
91
113
68 (74.7)
83 (73.5)
7.1 (1.3)
7.0 (.9)
92.5 (15.1)
90.3 (14.5)
144.93 (40.09)
140.47 (40.09)
57 (62.6%)
49 (43.4%)
Measures
Measure
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, • Direct child
Greenberg, & Beilke, 1988).
assessment
WISC-IV/WPPSI-lll
• Direct child
assessment
• Child Emotion identification
• Child Emotion understanding
• Child IQ functioning
Parent report - Oppositional
Defiant and Conduct Problems
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
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
Emotion Identification
Significant main effect for time only:
β = 2.37, SE = .48, t(180.4) = 4.91,
p = .000, 95%CI: 3.32,1.42
Emotion Understanding
Significant interaction Condition*Time:
β = 2.23, SE = .83, t(181.42) = 2.69,
p = .008, 95%CI: .59, 3.86, d = .50
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
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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
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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
[email protected]
• For Training Enquiries see our website
www.tuningintokids.org.au or contact Ann Harley,
Training Manager, 03 9371-0210
[email protected]
QUESTIONS &
ANSWERS
REMINDERS
•
Contact The ATAPS CMHS Clinical Support Service. Phone on
1800 031 185 or email [email protected]
•
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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