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Working with children with conduct problems and their families

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1 Working with children with conduct problems and their families
28th November 2013 10.30am-12.00pm AEDT

2 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

3 Love and eye contact in the aetiology and treatment of early-onset conduct problems. Mark R Dadds

4 Why study conduct problems?

5 Conduct disorders & operant/attachment theory

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 Aims Design 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.”

9 Viding, Blair, Moffitt & Plomin (2005)


11 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

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 gaze Ralph Adolph’s work

15 Observer Idea 1: Fear perception and theory of mind Fear stimulus
Aversive threat Information about environment from following other’s gaze Observer


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 caregiver Jones, W. et al. Arch Gen Psychiatry 2008;65: Copyright restrictions may apply.

21 Study 1:



24 But No control group Age spread Expensive coding Inappropriate tasks And….WARMTH!

25 Study 2:

26 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


28 The Eye-Love-You Game Healthy dyad:

29 The Eye-Love-You Game

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 parenting Arguments: Shaw et al (2005) – early versus late amygdala damage The primacy of parent-child eye contact Newman et al. And Dadds et al. on attentional manipulations

31 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)

32 Oxytocin and vasopressin levels after interaction with mothers

33 Reading the Mind in the Eyes Test
jealous panicked arrogant 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) systems Attention to emotional stimuli Quality of parenting - reciprocated love Pubertal transition Contagious affect Moral 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 children Behavioural experiments with eye contact (love and attachment) Emotion attention/recognition training Biobehavioural manipulations of the OXT system

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

41 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!

42 Working with Children with Conduct Problems:
1/04/2017 Working with Children with Conduct Problems: The Tuning in to Kids program Dr Sophie Havighurst This presentation is an overview of the Tuning in to Kids program developed in Melbourne Australia by Ann Harley and Sophie Havighurst For 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 by Sophie Havighurst and Ann Harley

43 Overview of Tuning in to Kids
1/04/2017 Overview of Tuning in to Kids

44 1/04/2017 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.

45 What is the TIK program? Six session, parenting group program
1/04/2017 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 6 – 8 sessions group program Booster sessions 1 or 2 group facilitators Run in kindergartens, schools, community centres Day or evening Group size: 8-14 participants

46 1/04/2017 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

47 Emotion Coaching To emotion coach your child you:
1/04/2017 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. 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 Model Tuning in to Kids Program Social/Cultural Factors Parent Functioning Emotion awareness Emotion wellbeing Family Functioning: Emotion climate Family of Origin experience with emotion Parenting: Attitudes/beliefs Emotion coaching Mindfulness Responsiveness Parent Meta-Emotion Philosophy Child Factors Temperament Neurophysiology Gender Cognition/language Child Emotion Competence Emotionality Emotion Regulation Emotion Knowledge Child Outcomes Behaviour Social Skills Academic Health

49 Why TIK with children with behaviour problems?
1/04/2017 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.

50 1/04/2017 TIK Research Evidence

51 Research on TIK and program variants
Tuning in to Toddlers Pilot study ( ) - MA student Michelle Lauw TIK Preschool Research Studies: pilot study ( ) RCT community efficacy trial ( ) Case studies with anxious children ( ) – PhD student Galit Hasen RCT clinical efficacy trial ( ) RCT community effectiveness trial ( ) DADS TIK pilot study (2011) DADS TIK RCT efficacy trial – ( ) TIK School Aged Research Studies RCT with conduct problem children - CASEA ( ) - PhD student Melissa Duncombe RCT clinical sample children with chronic illness ( ) - PhD student Wai Wai Yang Trauma-focused pilot study ( ) - with Australian Childhood Foundation Tuning in to Teens – Pre-adolescents and adolescents TINT (pre-adolescent) pilot study (2007) TINT (pre-adolescent) efficacy trial – RCT ( ) – PhD student Christiane Kehoe TINT (pre-adolescent) qualitative study ( ) – MA for Ann Harley TINT (adolescent) efficacy trial – RCT (2013 – 2017) We started with TIK – and have now trialed this in numerous settings and using different variants of the program These 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.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), 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 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.

55 1/04/2017 The use of an emotion coaching parenting program as part of an early intervention for children with emerging conduct disorder This 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 1/04/2017 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 Melissa 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 problems Triple 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 problems Universal School Intervention either: PATHS® (Promoting Alternative THinking Strategies) socio-emotional program Professional learning package for teachers Selective 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
1/04/2017 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 92.5 (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
1/04/2017 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 Child Emotion regulation Child Lability/negativity Eyberg Child Behavior Inventory (Eyberg & Pincus, 1999) Child Oppositional defiant disorder Child Conduct disorder Strengths and Difficulties Questionnaire (Goodman, 1997) Teacher report Child Behavior problems Metcalf Behavioural Checklist Child responsiveness Child confidence Kusche Affective Inventory (Kusche, Greenberg, & Beilke, 1988). Direct child assessment Child Emotion identification Child Emotion understanding WISC-IV/WPPSI-lll Child IQ functioning Schools 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
1/04/2017 Parent report - Oppositional Defiant and Conduct Problems Conduct Problems We 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 = .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

60 Teacher report - Behavior Difficulties
1/04/2017 Teacher report - Behavior Difficulties We also saw significant reductions in teacher’s reports of behaviour difficulties but not for the control group. Measure used was the Strengths and difficulties questionnaire Significant 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
1/04/2017 Direct Assessment Emotion Identification and Understanding Emotion Identification Emotion Understanding We 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 = .50 Significant main effect for time only: β = 2.37, SE = .48, t(180.4) = 4.91, p = .000, 95%CI: 3.32,1.42

62 1/04/2017 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 It worked really well to intervene directly with the child as well as with the parent.

63 1/04/2017 Key TIK strategies for working with parents who have a child with behaviour problems

64 Key strategies for parents
1/04/2017 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.

65 Key strategies continued…
1/04/2017 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.

66 1/04/2017 Case Study example

67 TIK Training and Dissemination
1/04/2017 TIK Training and Dissemination

68 TIK Training and Dissemination
1/04/2017 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.

69 Adaptations and use of TIK
1/04/2017 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.

70 Acknowledgements Program Authors: Sophie Havighurst and Ann Harley
1/04/2017 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

71 Contact Details address - Sophie Havighurst For Training Enquiries see our website or contact Ann Harley, Training Manager,


73 REMINDERS Contact The ATAPS CMHS Clinical Support Service. Phone on or 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 Please complete the Exit Survey – your feedback is appreciated! Upon closing…

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