Presentation on theme: "Working with children with conduct problems and their families"— Presentation transcript:
1 Working with children with conduct problems and their families 28th November 201310.30am-12.00pm AEDT
2 PRESENTERS: Professor Mark R Dadds Director of the Child Behaviour Research Clinic,Professor of Psychology,University of New South WalesDr Sophie HavighurstSenior Lecturer and Clinical PsychologistUniversity of MelbourneFacilitator: Bella Saunders, Senior Psychologist APS
3 Love and eye contact in the aetiology and treatment of early-onset conduct problems. Mark R Dadds
6 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?
7 AimsDesign assessments and interventions that are sensitive to child–specific ‘causal’ variables.
8 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.”
11 Attention in emotion processing Increasing evidence that various forms of psychopathology are associated with deficits in processing emotionsRelevant genotypes differently associated with amygdala activity to threatening facesPsychopathy associated with specific deficits in fear recognition and low amygdala responseAnxiety/depression/hot aggression associated with increased fear recognition and high amygdala response
12 Correlations between CU, Antisocial and accuracy of emotion recognition Dadds MR et al (2006). Look at the eyes: Fear recognition in child psychopathy. British Journal of Psychiatry, 189,
13 Munoz et al (2009) Journal of the American Academy of Child & Adolescent Psychiatry, 48,Blair et al (2002) – vocal cues.
14 Language of the eyes (super-stimuli) Amygdala and attention, social gazeRalph Adolph’s work
15 Observer Idea 1: Fear perception and theory of mind Fear stimulus Aversive threatInformation about environment from following other’s gazeObserver
17 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.
18 Eye Gaze Hotspots Hi CU boys “Cold’ conduct problems Healthy boys Dadds et al. (2008) J Amer Acad Child Adolesc Psych.
19 So?Does it happen in the real world?With attachment figures?
20 Example visual scan-paths and fixation time summaries for 3 toddlers watching the same video of an actress playing the role of a caregiverJones, W. et al. Arch Gen Psychiatry 2008;65:Copyright restrictions may apply.
30 Interpretations Low eye contact is just another marker of low empathy Low eye contact drives the development of low empathy and low susceptibility to parentingArguments:Shaw et al (2005) – early versus late amygdala damageThe primacy of parent-child eye contactNewman et al. And Dadds et al. on attentional manipulations
31 OXYTOCINOxytocin“who’s important to me, who I’d die for, who I’m pair-bonded with, who will take care of me,”(Thomas Insel)
32 Oxytocin and vasopressin levels after interaction with mothers
33 Reading the Mind in the Eyes Test jealous panickedarrogant hateful
34 Guastella A, Dadds MR, & Mitchell PB Guastella A, Dadds MR, & Mitchell PB. (2009) Oxytocin increases gaze to the eye-region of human faces. Biological Psychiatry.
37 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.
38 Attention to emotional stimuli OXT (/SERT) systemsAttention to emotional stimuliQuality of parenting - reciprocated lovePubertal transitionContagious affectMoral conscience
39 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 childrenBehavioural experiments with eye contact (love and attachment)Emotion attention/recognition trainingBiobehavioural manipulations of the OXT system
40 Dadds, Cauchi, Wimalaweera, Hawes, & Brennan Dadds, Cauchi, Wimalaweera, Hawes, & Brennan. Psychiatry Research (in press).
41 Thanks toSydney:David Hawes, John Brennan, Caroline Moul, Subodha Wimmalaweera, Dave Pasalich, Jasmin Jambrak, Avril CauchiLondon:Stephen Scott, Jen Allen, Bonamy Oliver, Nathan Faulkner, Kat Legge, Caroline Moul, Matt WoolgarThank YOU!
42 Working with Children with Conduct Problems: 1/04/2017Working with Children with Conduct Problems:The Tuning in to Kids programDr Sophie HavighurstThis presentation is an overview of the Tuning in to Kids program developed in Melbourne Australia by Ann Harley and Sophie HavighurstFor ATAPS the presesntation will include: Theory around the Tuning into kids intervention, evidence/findings, and some case examples/practical examples /insights into working with this population.Written bySophie Havighurst and Ann Harley
43 Overview of Tuning in to Kids 1/04/2017Overview of Tuning in to Kids
44 1/04/2017Tuning in to Kids (TIK) is an evidence- based program that helps parents teach their children about emotions while building a close and supportive relationship.
45 What is the TIK program? Six session, parenting group program 1/04/2017What is the TIK program?Six session, parenting group programFocus on emotions in parents and childrenParents become aware of their child’s emotions and coach their child in being able to understand and regulate emotionsParents become aware of and regulate their own emotions when parentingIn children - prevents problems from developing, or reduces problems that existCan be used in individual therapy6 – 8 sessions group programBooster sessions1 or 2 group facilitatorsRun in kindergartens, schools, community centresDay or eveningGroup size: 8-14 participants
46 1/04/2017Theoretical BasisBased 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 relationshipsDraws on aspects of social learning theory, attachment theory, mindfulness and emotion coaching
47 Emotion Coaching To emotion coach your child you: 1/04/2017To 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 teachingCommunicate your understanding and acceptance of the emotion – empathyHelp them use words to describe what they feelIf 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.Cover these reasonably briefly but perhaps give a basic example of each step.Many similarities with all age groups eg understanding how discipline can be teaching not punishment;avoiding time out (unless fundamental for parent/child safety) but encouraging time in;
48 Tuning in to Kids Program TIK Theoretical ModelTuning in to Kids ProgramSocial/Cultural FactorsParent FunctioningEmotion awarenessEmotion wellbeingFamily Functioning:Emotion climateFamily of Origin experience with emotionParenting:Attitudes/beliefsEmotion coachingMindfulnessResponsivenessParent Meta-Emotion PhilosophyChild FactorsTemperamentNeurophysiologyGenderCognition/languageChild Emotion CompetenceEmotionalityEmotion RegulationEmotion KnowledgeChild OutcomesBehaviourSocial SkillsAcademicHealth
49 Why TIK with children with behaviour problems? 1/04/2017Why TIK with children with behaviour problems?Diverse approaches are neededStrategies for increasing attachment and building close connections between parents and childrenAssist parents to shift from automatic patterns in parentingPut developmental theories about emotional intelligence/competence into actionUnderstand the emotional needs that lie behind challenging behavioursA complement for behavioural techniques (such as Triple P) or a different approach altogether.
51 Research on TIK and program variants Tuning in to ToddlersPilot study ( ) - MA student Michelle LauwTIK Preschool Research Studies:pilot study ( )RCT community efficacy trial ( )Case studies with anxious children ( ) – PhD student Galit HasenRCT clinical efficacy trial ( )RCT community effectiveness trial ( )DADS TIK pilot study (2011)DADS TIK RCT efficacy trial – ( )TIK School Aged Research StudiesRCT with conduct problem children - CASEA ( ) - PhD student Melissa DuncombeRCT clinical sample children with chronic illness ( ) - PhD student Wai Wai YangTrauma-focused pilot study ( ) - with Australian Childhood FoundationTuning in to Teens – Pre-adolescents and adolescentsTINT (pre-adolescent) pilot study (2007)TINT (pre-adolescent) efficacy trial – RCT ( ) – PhD student Christiane KehoeTINT (pre-adolescent) qualitative study ( ) – MA for Ann HarleyTINT (adolescent) efficacy trial – RCT (2013 – 2017)We started with TIK – and have now trialed this in numerous settings and using different variants of the programThese are the current or completed research studies on TIK or its variants
52 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),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),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),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),Havighurst, S. S., & Harley, A. E. (2013). Tuning in to Kids: Emotion coaching for early learning staff. Belonging: Early Years Journal, 2(1),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).These are the current publications (under review (as in being considered); in press (accepted but not yet out) or published.
53 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: /sode.12060Kehoe, 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),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.
54 Research trials of TIK with children with behaviour problems Clinical/sub-clinical trialsPreschool 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’sPreschool efficacy trialPre-adolescent efficacy trial.
55 1/04/2017The use of an emotion coaching parenting program as part of an early intervention for children with emerging conduct disorderThis study was a collaboration between our team, PhD student Melissa Duncombe and two clinical services who were developing an early intervention for children with emerging conduct disorders. CASEA (CAMHS and Schools Early Action program) is a State government funded initiative. The two teams were Austin CASEA (a metro Melbourne sample) and Bendigo (including regional and rural sample). We targeted all low SES schools for this study.We trialed TIK in combination with a school/teacher intervention and a child social-emotional group program where we compared TIK with Triple P.We also conducted a comparison of TIK with Triple P.Child and Adolescent Mental Health Service
56 1/04/2017Research MethodPrep-Grade 3 children from 48 schoolsRandomized by school into two intervention conditions (Tuning in to Kids or Triple P) or 12 month waitlist controlAssessment baseline and 10 month follow-upParent/teacher Questionnaires plus direct child assessmentSchool-wide universal intervention, parent and child groups and referral on as neededMelissa Duncombe’s PhD compared TIK and Triple P. Results were that the programs were equivalent in terms of leading to significant reductions in behaviour problems on parent and teacher report and on direct child assessment. Other key points were:TIK led to better outcomes when parents had higher levels of mental health problemsTriple P worked better for younger children – however, we’ve also shown TIK works well with the preschool population.Universal screening - 4,752 Prep – Grade 3 children for behaviour problemsUniversal School Intervention either:PATHS® (Promoting Alternative THinking Strategies) socio-emotional programProfessional learning package for teachersSelective Intervention – 8-session parent group (TIK) and 8-session socio-emotional child group (based on Fast Track and Exploring Together)After selective intervention – if needed, referral on to other services (CAMHS), speech-language, etc
57 Participant Demographics 1/04/2017Participant DemographicsVariableInterventionControln91113Child Gender(% Male)68 (74.7)83 (73.5)Age in yearsM (SD)7.1 (1.3)7.0 (.9)Pro-Rated Full Scale IQ92.5 (15.1)90.3 (14.5)Eyberg Child Behavior Inventory Intensity Score - M (SD)(40.09)(40.09)Gross Annual Income(% Low Income <$60,000)57 (62.6%)49 (43.4%)Just put this slide up and say that the sample for this study was N = 204 children with emerging conduct disorder – mostly male. Families were predominantly low income.
58 Measures Measure Source Construct 1/04/2017MeasuresMeasureSourceConstructMaternal Emotional Style Questionnaire (Lagacé-Séguin & Coplan, 2005)Parent reportParent emotion dismissingParent Emotion coachingParent EmpathyEmotion Regulation Checklist Shields & Cicchetti, 1997Child Emotion regulationChild Lability/negativityEyberg Child Behavior Inventory (Eyberg & Pincus, 1999)Child Oppositional defiant disorderChild Conduct disorderStrengths and Difficulties Questionnaire (Goodman, 1997)Teacher reportChild Behavior problemsMetcalf Behavioural ChecklistChild responsivenessChild confidenceKusche Affective Inventory (Kusche, Greenberg, & Beilke, 1988).Direct child assessmentChild Emotion identificationChild Emotion understandingWISC-IV/WPPSI-lllChild IQ functioningSchools were randomised into intervention or control (wait list until 1 year later)This was the suite of measures delivered pre and approximately 1 year later for both intervention and controls. You don’t need to go through these measures. Could just say that we got parent reports, teacher reports and direct assessments of children
59 Parent report - Oppositional Defiant and Conduct Problems 1/04/2017Parent report - Oppositional Defiant and Conduct ProblemsConduct ProblemsWe saw significantly improved child oppositional and conduct problems (on the Eyberg Child Behavior Inventory) but not for the control group.Significant interaction Condition*Time:β = -7.62, SE = .2.95, t(150.96) = -2.58,p = .011, 95%CI: , -1.80, d = .37Significant interaction Condition*Time:β = -4.84, SE = 1.91, t(156.20) = -2.53,p = .012, 95%CI: -8.61, -1.07, d = .37
60 Teacher report - Behavior Difficulties 1/04/2017Teacher report - Behavior DifficultiesWe also saw significant reductions in teacher’s reports of behaviour difficulties but not for the control group. Measure used was the Strengths and difficulties questionnaireSignificant interaction Condition*Time:β = -3.01, SE = 1.01,t(176.64) = -2.98,p = .003, 95%CI: -5.01, d = .41
61 Direct Assessment Emotion Identification and Understanding 1/04/2017Direct Assessment Emotion Identification and UnderstandingEmotion IdentificationEmotion UnderstandingWe also saw significant improvements on parents empathy and reductions in dismissing. They are not reported here. Just reporting on child outcomes here.The main child outcomes were that we saw significant improved emotion understanding for intervention group only. All children in both samples improved on emotion identification – which you often find with measures that capture normal developmental changes.Significant interaction Condition*Time:β = 2.23, SE = .83, t(181.42) = 2.69,p = .008, 95%CI: .59, 3.86, d = .50Significant main effect for time only:β = 2.37, SE = .48, t(180.4) = 4.91,p = .000, 95%CI: 3.32,1.42
62 1/04/2017ConclusionsThe 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 childParenting significantly improved with reduced emotion dismissiveness and increased empathyThe child and parent programs were complementaryIt worked really well to intervene directly with the child as well as with the parent.
63 1/04/2017Key TIK strategies for working with parents who have a child with behaviour problems
64 Key strategies for parents 1/04/2017Key strategies for parentsAttend to low intensity emotions in contrast to use of planned ignoringEmotion coach the feelings behind anger rather than just focus on the angry behavioursAssist parents to see the difference between angry emotions and behaviourEncourage acceptance of emotions and differentiate some behaviours are acceptable and some are notUse of limit setting and family rulesExamine parents own emotional reactions to children’s emotions (especially anger) and explore their family of origin experience with emotionsHelp parents develop skills in their own emotion awareness and regulation as well as self-care.
65 Key strategies continued… 1/04/2017Key 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 outEmotion coaching may be used a little during highly emotional times (name the emotion) but especially used afterwards when emotions have reducedLinks are made to neurobiology where prefrontal cortex is less functional when very emotional – parents are encouraged to use less talk at these timesTeach 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.
67 TIK Training and Dissemination 1/04/2017TIK Training and Dissemination
68 TIK Training and Dissemination 1/04/2017TIK Training and Dissemination2 day training workshop for facilitators with ongoing supervision to assist with deliveryIn-service training options provided and tailored to the service and skill level of staffUse of a structured manualSince 2007 over 2500 professionals trainedTranslations of parent handouts into Somali, Arabic, Vietnamese, Amharic, Cantonese.
69 Adaptations and use of TIK 1/04/2017Adaptations and use of TIKCAMHS and CASEAAustralian Childhood Foundation – traumaInpatient CAMHSDrug and Alcohol RehabilitationPrisonsEducational settings including teacher educationIndigenousMulti-culturalYoung single mothers playgroupsKinship carers, grandparents and foster carers.
70 Acknowledgements Program Authors: Sophie Havighurst and Ann Harley 1/04/2017Program Authors: Sophie Havighurst and Ann HarleyResearch 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 StargattResearch Collaborators:Mindful, Department of Psychiatry, University of MelbourneParentsLink at MacKillop Family ServicesCentre for Community Child Health, RCHDianella Community HealthKnox City CouncilAustralian Childhood FoundationCASEA - Bendigo and Austin CAMHSResearch Funded by:Australian Rotary HealthFinancial Markets Foundation for ChildrenWilliam Buckland FoundationUniversity of MelbourneHelen Macpherson Smith Trust
71 Contact Detailsaddress - Sophie HavighurstFor Training Enquiries see our website or contact Ann Harley, Training Manager,
73 REMINDERSContact The ATAPS CMHS Clinical Support Service. Phone on orNext Wednesday webinar on working with young children and a further series in 2014A recording of the webinar will be available on the APS website shortly. SeePlease complete the Exit Survey – your feedback is appreciated!Upon closing…