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Daniel A. Waschbusch, Ph.D.
Penn State Hershey Medical CenterDepartment of Psychiatry
Florida International UniversityCenter for Children and FamiliesDepartment of Psychology
Funding to Waschbusch from NIMH, SSHRC, NSHRF, IWK health center, CIBC miracle network, Dalhousie University,
Disclosures: JACP editing stipendPast funding from drug companies but not for any of this work
CollaboratorsMike WilloughbyBill PelhamSarah HaasNorm CarreyGreg FabianoJim WaxmonskyLisa Burrows-MacLeanSara KingBrendan AndradeAndrew GreinerBeth GnagyOmar KazmiKerry RoachMany undergrad RAsCounselors in the STPKids and parents in the studies
Common reasons for mental health services (Frick & Silverthorn, 2001)
Negative impact on families (Frick, Lahey et al 1992) and schools (Gottfredson & Gottfredson, 2001)
Relatively prevalent5% to 10% of kids in pediatric care settings (Costello, 1989)
High financial cost to society$70,000 per child over seven years (Foster, Jones, & CPPRG (2004)
DSM-IV categoriesOppositional Defiant Disorder
Negative, hostile, argumentative behaviorConduct Disorder
Aggression to people and animalsDestruction of propertyDeceitfulness or theftSerious rule violations (e.g., truancy, running away)
Both categories also require Patterns of behaviorSerious impairmentExceed developmental norms
Disruptive Behaviors (from Loeber et al, 1992) Age
Cruel to others, stealing, running away 14
from home, truancy, breaking and entering, 13
assault 12
11
10
Lies, physical fights, bullies others, 9
Cruel to animals, breaks rules 8
7
6
Oppositional, defiant, stubborn, noncompliant, 5
tempter tantrums 4
Hyperactive, Impulsive 3
2
Difficult temperament 1
Developmental progression of population masks individual differences (Loeber & Stouthamer-Loeber, 1998)
Benefits of understanding individual differences includes improvement in:
Understanding of correlates and causal pathwaysMatching intervention to need
Lower costBetter outcomes
Childhood onsetEmerge before age 10 to 12Associated with with numerous dispositional and contextual risk factors
Adolescent onsetEmerge after age 10 to 12Associated with contextual risk factors
Supported by decades of research (Robbins, 1970’s; Moffitt, 1993, 2003; Loeber, 1988)
Childhood Onset Adolescent OnsetFamily dysfunction RebelliousLow verbal IQ Reject social norms / hierarchiesNegative / Ineffective parenting Affiliate with deviant peersDeviant social cognition Low parental monitoring /
supervisionPeer / Social rejectionInattentionPoor impulse control
Moffitt, 1993, 2003; Loeber, 1988; many others
Not all child-onset cases have poor outcomes50% persist, 50% desist (Loeber, 1982; Olweus, 1982)
Not all adolescent-onset cases desistCan get “trapped” in antisocial lifestyle
arrest, school drop out, teenage pregnancy, etc.
Likely many different trajectories (Loeber & Stouthamer-Loeber, 1998)
Childhood onset that persists or desistsAdolescent onset that persists or desistsAdult onset that persists of desists
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
13 14 15 16 17 18 19 20 21 22 23 24 25
Prob
abili
ty o
f Ser
ious
Vio
lenc
e
Age
NoneChild onset persistChild onset desistAdol onset
Loeber, Farrington, Stouthamer-Loeber & White, 2008
0
1
2
3
4
5
6
7
8
Variety Number
Aver
age
#
Official Convictions at Age 26
None (56%)
Child onset persist (10%)
Child onset desist (8%)
Adol onset (26%)
Moffitt, Caspi, Harrington, & Milne (2002)
0
5
10
15
20
25
30
35
Self reported violence Violence conviction
% o
f Gro
up
Violence at Age 32
None (46%)
Child onset persist (11%)
Child onset desist (24%)
Adol onset (20%)
Odgers, Moffitt et al (2008)
0
5
10
15
20
25
30
35
Psychiatric Disorder Mental Health Impairment
% o
f Gro
up
None (46%)
Child onset persist (11%)
Child onset desist (24%)
Adol onset (20%)
Odgers et al (2007)
0
10
20
30
40
50
60
70
Good / Excellent Health Hospitalized Past Year
% o
f Gro
up
None (46%)
Child onset persist (11%)
Child onset desist (24%)
Adol onset (20%)
Odgers et al (2007)
0
1
2
3
4
5
6
# GP visits Physical health problems
Aver
age
# in
Pas
t Yea
r
None (46%)
Child onset persist (11%)
Child onset desist (24%)
Adol onset (20%)
Odgers et al (2007)
Different pathways to antisocial behaviorChildhood onset = greatest persistence and severity
But also differences within child-onsetPersistently antisocial vs. desist over development
Suggests need to differentiate within child-onsetCallous-Unemotional traits may be a useful construct for this purpose
Evidence throughout history, even in ancient timesE.g., Nero
Poisoned his stepbrotherMurdered his motherKicked his 2nd wife to death when she was pregnantBurned captured Christians in his garden as a source of light
Hervey Cleckley (1941)Case studies of several individuals who
Were irresponsible but not necessarily violent, aggressive, antisocialSeemed unconcerned about the impact of their behaviors on themselves or others
Based on these, proposed 16 common features One of 1st to conceptualize psychopathy as having underlying pathology despite outward appearance of robust mental healthBecame foundation of all subsequent work
David Lykken (1957)First empirical test of Cleckley’s conceptualizationFirst evidence for several constructs that remain central to understanding psychopathy
Passive avoidance deficit (deficient learning from punishment )Decreased skin response to punishmentDecreased anxiety
Bob Hare (1970s and 1980s)Developed the Pscyhopathy Checklist (PCL) and PCL-R to operationalize Cleckley’s criteriaPropelled an enormous amount of psychopathy researchCurrently most prominent psychopathy researcher
Deficient affective experienceLack of remorse or guiltShallow affectCallous / lack of empathy
Arrogant and deceitful interpersonal styleSuperficial charmConning / manipulativePathological lying
Irresponsible and impulsive lifestyleLack of long term goalsFailure to accept responsibility for own actionsParasitic lifestyle
Cooke & Michie (2001); Hare (2006); Patrick (2010)
More serious and violent crimes (Campbell, Porter & Santor, 2004)
Account for large portion of “cold blooded” murder (Woodworth & Porter, 2002; Porter et al, 2003)
Higher rates of recidivism (Salekin, 2008)
Less responsive to treatment – may get worse rather than better (Harris & Rice, 2006)
Over-focused on rewards and less responsive to punishment (Newman, 1998)
Less physiological arousal (Patrick, 2007)
Reduced empathy / response to fear in others (Patrick, 2001)
125 adults who committed homicide34 psychopaths, 91 non-psychopaths
Compared characteristics of the homicidesMurders perpetrated by psychopaths:
Almost twice as likely to be instrumentalLess likely to have impulsive and anger features
In short, psychopathy more highly associated with “cold blooded” murder
Woodworth & Porter (2002)
Characterized by:Lack of remorse or guilt after doing wrongLack of empathy or concern for others (callous)Unconcerned about own performanceShallow or deficient affect
Modifier of conduct disorder in DSM-Vlimited prosocial emotions
Reduced reactivity to anticipated aversives?
Are CU Traits real?Are they prevalent enough to care about?Should we study CU traits?Do CU traits matter?What do we do to help kids who show them?
Are CU Traits real?Are they prevalent enough to care about?Should we study CU traits?Do CU traits matter?What do we do about them?
Item Alternative Interpretation
Impairment Items
3. Is concerned about how well he/she does in school School impairment
7. Is good at keeping promises ADHD
20. Keeps the same friends Peer impairment
Affect / CU Items
12. Feels bad or guilty when she/he does something wrong Affect / CU
18. Is concerned about the feelings of others Affect / CU
19. Does not show feelings or emotions Affect / CU
“Isn’t CU really just a marker for impairment?” – me, repeatedly, 1999 or so
Antisocial Process Screening Device – CU Scale:
How does APSD perform when you divide the “impairment” vs. CU items?Clinical sample
Halifax Summer Treatment Program intakes 2001-2003Parent and teacher ratings on about 180 children
APSDDisruptive Behavior Disorder - ADHD, ODD, CDImpairment Rating ScaleReact/Proact/Relationship Aggression
Impairment items on CU scale Affect items on CU Scale
Impairment Items Mom Teacher Mom Teacher
Mom ‐‐
Teacher .28* ‐‐
Affect Items
Mom .73* .24* ‐‐
Teacher .36* .54* .41* ‐‐
Red font = cross-informant correlation of same trait
Impair Controlling Affect Affect Controlling Impair
Overall Impair Mom Teacher Mom Teacher
Mom .39* .10 .11 .29*
Teacher .30* .12 .04 .28*
React Aggress
Mom .20* .05 .33* .17*
Teacher .17* .21* .20* .22*
Proact Aggress
Mom .11 .02 .36* .20*
Teacher .03 .05 .23* .31*
Relate Aggress
Mom .05 ‐.07 .36* .37*
Teacher .01 .07 .13 .32*
Community sampleBEST Project: Elementary school intervention implemented in six schoolsParent and teacher ratings on about 1550 children at baseline
MeasuresCU Screening measure
Three items generated by psychopathy experts:Lacks remorseSeems to enjoy being meanIs cold or uncaring
Likert Ratings from 0 (“not at all” ) to 3 (“very much”)
Mom Teacher
Overall Impair
Mom .53* .25*
Teacher .18* .53*
React Aggress
Mom .60* .24*
Teacher .21* .67*
Proact Aggress
Mom .67* .30*
Teacher .13 .66*
Relate Aggress
Mom .55* .11
Teacher .15 .59*
Parent CU with Teacher CU: r = .22*
Slenderman Stabbing, Wisconsin, June 2014Two 12 year olds stabbed another 12 year old 19 times to induce a visit from “slenderman”
NY Times Article, June 8, 2014:
Evidence that CU traits are “real”Statistical evidence that they are not just a marker for impairmentAnecdotal evidence that they present in important ways “in the real world”
Newer CU measures largely avoid the potential “impairment confound” problem
Are CU Traits real?Are they prevalent enough to care about?Should we study CU trait?Do CU traits matter?What do we do about them?
Justice settings20% of adolescent offenders (Lindberg, 2009; Salekin, 2004)
Community settings (Rowe, Maughan et al, 2010)
1% CD/CU1% CD-only3% CU-only
Clinical settingsMost clinicians believe they have treated children with high CU traits (Salekin et al, 2001)
30% to 50% of children with CP (Frick et al, 2014)
Evidence that CU is normally distributed within CP
Community Sample
78.7
15.9
4.1 1.4
87.3
10.3
2.0 0.40.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Not at all Just a little Prettymuch
Very much
% o
f Sex
Boys (n = 806)
Girls (n = 741)
Clinic Sample
31.227.0 25.5
16.3
52.5
22.515.0
10.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Not at all Just a little Prettymuch
Very much
% o
f Sex
Boys (n =141)
Waschbusch et al; 2005 Waschbusch et al; 2007
Sex
0
5
10
15
20
25
30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85
% o
f Sam
ple
T-Score from the APSD CU Scale
Boys (n = 144)Girls (n = 41)
Waschbusch et al; 2007 – STP 2001 - 2003
Non-CP
0
5
10
15
20
25
30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85
% o
f Sam
ple
T-Score from the APSD CU Scale
Not CP (n=56)
Waschbusch et al; 2007 – STP 2001 - 2003
ODD
0
5
10
15
20
25
30
35
30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85
% o
f Sam
ple
T-Score from the APSD CU Scale
ODD (n = 62)
Waschbusch et al; 2007 – STP 2001 - 2003
CD
0
5
10
15
20
25
30
35
30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85
% o
f Sam
ple
T-Score from the APSD CU Scale
CD (n = 65)
Waschbusch et al; 2007 – STP 2001 - 2003
Diagnosis
0
5
10
15
20
25
30
35
30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85
% o
f Sam
ple
T-Score from the APSD CU Scale
Not CP (n=56)ODD (n = 62)CD (n = 65)
Waschbusch et al; 2007 – STP 2001 - 2003
Community Sample
99.886.1
53.4
0.2
13.9
46.6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
None ODD CD
% o
f Sa
mpl
e
None CU
Clinic Sample
98.0
71.7
24.6
2.0
28.3
75.4
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
None ODD CD
% o
f Sa
mpl
e
None CU
Waschbusch et al; 2005 Waschbusch et al; 2007
Informant
0
5
10
15
20
25
30
35
40
45
0 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 70 to 72
% o
f Sam
ple
Total Score from the ICU
Teacher (n = 143)
Parent (n = 165)
Waschbusch & Pelham – STP 2011-2012
CU Traits are not uncommon4% of normal population
1 kid in every classroomNormally distributed among clinical samples
Are CU Traits real?Are they prevalent enough to care about?Should we study CU?Do CU traits matter?What do we do about them?
Antisocial Process Screening Device (APSD) (Frick & Hare, 2001)
Likert Ratings – parent, teacher, self report versionsPros
Six items – easy and fastFactor structure, validity, test-retest reliability well supportedPublished normsWidely used – default measure of CU in kids
ConsLow alphas in some studiesOnly six items --
Other measures – promising, but not establishedInventory of Callous-Unemotional Traits (Frick)Child Psychopathy Scale – Revised (Lynam)Dadds revision of the APSD (Mark Dadds)
Most of these – including APSD – use positively worded items that are reverse scored.
Is failure to endorse “feels bad when he/she does wrong” the same as endorsing “does not feel bad when he/she does wrong”?
RisksHighly negative connotation; stigmatizing
Comes out of psychopathy research
Often viewed as a stable, untreatable condition
The risks can be mitigatedEducation about developmental and individual differencesCareful application of the construct in clinical, educational, judicial contexts
Don’t get carried away
-The Onion (Dec 7, 2009)
Children display hallmarks of psychopathy:Poor impulse/anger controlLittle regard for how own behavior affects othersWill exploit others to get what they wantQuickly become boredNeed constant attention and validationEgocentric
BenefitsMay improve understanding of the most seriously impaired children which in turn…May lead to better treatments, which in turn…May lead to better outcomes
Opportunity cost: there are risks of not pursuing this line of work
Miss chance to deflect trajectory of those at highest risk for the most seriously antisocial behaviors
“Conscience does make cowards of us all”--William Shakespeare in Hamlet
Self-reported key traits for success as a venture capitalist:
DeterminationCuriosityInsensitivity
CU does not condemn one to a life of crime and can be associated with success
“I always said he would grow up to be either a Nobel prize winner or a serial killer”
– mom of 9 year old boy with high CU
“The road to the top is hard. But it’s easier to climb if you lever yourself up on others. Easier still if they think something’s in it for them”
– Anonymous CEO
Kevin Dulton (2012) – The Wisdom of PsychopathsJennifer Kahn (2012) – NY Times Magazine
“It’s not just enough to fly in first class; I have to know my friends are flying in coach”
– Jeremy Frommer, CEO, Carlin Financial
The great thing about insensitivity is “…it lets you sleep at night”
– Jon Moulton, venture capitalist, Financial Times interview
Kevin Dulton (2012) – The Wisdom of PsychopathsMichael Lewis (March 31, 2014) - New York Times Magazine
“I have no compassion for those whom I operate on. That is a luxury I simply cannot afford. When I am in the theater I am reborn as a cold, heartless machine, totally at one with scalpel, drill, and saw. When you’re cutting loose and cheating death high above the snowline of the brain, feelings aren’t fit for purpose. Emotion is entropy – and seriously bad for business. I’ve hunted it down to extinction over the years”
--Anonymous Neurosurgeon
Kevin Dulton (2012) – The Wisdom of Psychopaths
CU Traits in kids:Are realHave high potential to stigmatizeAlso high potential to identify kids who need helpDo not condemn kids to a life of crime
Are CU Traits real?Are they prevalent enough to care about?Should we study CU?Do CU traits matter?What do we do about them?
5% of children in community sample30% to 50% in clinic referred CP sample
May be normally distributed in clinic samplesNon-overlapping with ODD/CD
25% to 50% of ODD/CD in community sample50% to 75% of ODD/CD in clinical sample
More prevalent in boys than girlsOther research suggests there may be different etiological underpinnings as well (Dadds et al 2009; Fontaine et al, 2010)
0
20
40
60
80
100
120
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Num
ber
of P
ublic
atio
ns
Publication Year
Salekin & Lynam (2010) – estimated from fig 1.1
Frick et al (2014) – review in Psyc Bull269 studies of CU traits since 1990
Of these, 191 (71%) published in 2007 or later
Focused on studies that compared CPCU vs. CP-only
Differences in many areas including...
Frick et al (2014)
Moral DevelopmentLess empathy for victims (Pardini et al, 2003; Hastings et al, 2000)
Less able to distinguish moral violations from conventional violations (Blair, 1997, 2001; Fisher & Blair, 1998)
Frick et al (2014)
Emotional ProcessingLess accurate at identifying fear, sadness (Blair et al, 2000, 2001, 2005, Dadds et al, 2006; Woodworth & Waschbusch, 2008)
Less physiological, behavioral response to distress and to negative emotional cues (Frick et al, 2003; Kimonis et al, 2006; Loney et al 2003; Marsh et al, in press; Sharp et al, 2006)
Frick et al (2014)
Cognitive abilitiesLess likely to change behavior in response to punishment (Barry et al, 2000; Budhani & Blair, 2005; O’Brien et al, 1996)
Higher verbal IQ (no diffs vs. controls) (Christian et al, 1997; Loney et al, 1998)
Frick et al (2014)
Computer tasks argue that CU kids react differently to reward and punish
Card playing task and its variants most commonPlay 100 cardsFirst 10 cards: all reward no point lossNext 10 cards: 9 reward, 1 point lossNext 10 cards: 8 reward, 2 point lossEtc.DV = how many cards will kids play until they stop?
0
50
100
150
200
250
300
350
Non-Anxious CU Anxious CU Controls
# of
Car
s Pla
yed b
b
O’Brien & Frick, 1996
a
0
50
100
150
200
250
300
350
Group
# of
Tri
als
Clinic ControlADHD-onlyADHD/CP-onlyADHD/CP-CU
a aa
b
Barry et al, 2000
BiologyLess amygdala activation when processing fear (Jones et al, 2009; Marsh et al, 2009)
Abnormal ventromedial prefrontal cortex activation during a punishment reversal task (Finger et al, 2008)
Lower HR at baseline and in emotional situations (Raineet al, 2005; Amastassiou-Hadjicharalmbous & Warden, 2008)
Lower salivary cortisol but no differences on testosterone (Loney et al, 2006)
Frick et al (2014)
Co-Occurring problemsLower likelihood of anxiety (Frick, Lilienfeld et al, 1999)
Less likely to commit suicide (Javdani, Sadeh, & Edelyn, 2011)
Specific and unique associations with proactive aggression (Frick & Ellis, 1999; Waschbusch & Willoughby, 2007)
Role of ADHD unclear
Frick et al (2014)
Genetic / Family StudiesGenetics account for 42% to 68% of CU2-3 times greater heritability of antisocial behavior in CP/CU (Viding et al, 2005)
Antisocial Personality and Arrest 3-6 times higher in CP/CU parents than in CP-only parents (Frick et al, 1994; Christian et al, 1997)
Frick et al (2014)
30
34
36
CP-only
Genetics
Sharedenvironment
Nonsharedenvironment
810
36
CP/CU
Genetics
Sharedenvironment
Nonsharedenvironment
Viding et al (2005)
Social CognitionAccurately interpret peer intent (unlike CP-only) (Frick et al, 2003; Waschbusch, et al, 2009)
More aggressive responses before and after provocation from a peer (Munoz et al, 2008; Waschbusch et al, 2009)
No difference in types of solutions generated in response to social problems (Waschbusch et al, 2007)
More positive evaluations of aggressive solutions (Pardini et al, 2003)
Believe aggression will have more positive, fewer negative consequences
Believe aggression will succeed
0.80.850.9
0.951
1.051.1
1.151.2
1.251.3
Overtly aggressive ProsocialType of Solution
ControlCU-onlyCP-onlyCP/CU
Waschbusch, Walsh et al (2007)
Antisocial BehaviorCPCU and CP-only compared in 118 studies 89% provide evidence of greater antisocial in CPCU
More severe, varied and frequent (Frick et al, 2003, 2005; Pardini et al, 2006, 2008;)
More delinquency / recidivism (Christian et al 1997; Falkenbach et al. 2003)
CU independently predicts antisocial behavior in adolescence and early adulthood (Loeber et al, 2002, 2008; Lynam, 1997; McMahon et al, 2010)
Frick et al (2014)
0
10
20
30
40
50
60
70
Any Violence Status
% of G
roup
Type of Delinquent Act
ControlCU‐onlyCP‐onlyCP/CU
Frick, Cornell et al (2003)
60 Participants32 Controls14 with CP-only14 with CP/CU
Competed in reaction time taskWins and losses fixed ahead of timeStandardized provocations (low or high) from a “peer”No real peer – actually a computer
Two aggression conditionsInstrumental
0 to 10 points“It will make it harder for him/her to win the game”
Hostile: 0 to 10 seconds of white noice0 to 10 seconds of white noise burst“It won’t make it harder for him/her to win the game, but it really bugs other kids”
Helseth, Waschbusch et al, in press, JACP
When they lost, “opponent” would provoke themLow provocation:
Took 0 to 2 points / white noise burst“You lost, but you’re getting better”
High provocation:Took 8 to 10 points / white noise burst“Nice try speedo! What’s the matter is your hand stuck in cement?”
When they won, “opponent” would provoke themSent a consequence to “opponent”
Instrumental aggression: 0 to 10 pointsHostile aggression: 0 to 10 seconds of white noise burst
Sent a message to opponentOnly presenting instrumental condition
Most consistent with past researchResults similar across conditionsBoth conditions get complex and messy in presentation format
Helseth, Waschbusch et al, under review
Behavior
0
1
2
3
4
5
6
7
8
9
10
Agg
ress
ion
ControlCP-onlyCP/CU
a
b
a
Affect
0
0.5
1
1.5
2
2.5
3
3.5
4
Ang
er
ControlCP-onlyCP/CU
Behavior
0
1
2
3
4
5
6
7
8
9
10
Low High
Agg
ress
ion
Level of Provocation
ControlCP-onlyCP/CU
a
a
b
Affect
0
0.5
1
1.5
2
2.5
3
3.5
4
Low High
Ang
er
Level of Provocation
ControlCP-onlyCP/CU
Behavior
0
1
2
3
4
5
6
7
8
9
10
1 2 3 4 5 6
Agg
ress
ion
Final Trials of Task
ControlCP-onlyCP/CU
Highly Provoked By “Opponent”
Affect
0
0.5
1
1.5
2
2.5
3
3.5
4
1 2 3 4 5 6
Ang
er
Final Trials of Task
ControlCP-onlyCP/CU
Highly Provoked By “Opponent”
Under-regulated pathway – ADHD/CP-onlyDifficult temperament
impulsive, quick to anger, reactive
Interacts with ineffective parentingharsh, inconsistent discipline, poor monitoring and supervision, low positives, etc.
Under-arousal pathway – ADHD/CP-CULow physiological arousal in response to:
Punishment / parent socializationOther’s distress
EvidencePhysiological under-arousal when anticipating aversive stimuli at 3 years significantly associated with:
Aggression at 8 years (Gao, Raine et al, 2010a)
Crime at 23 years (Gao, Raine, et al, 2010b)
Behavioral under-arousal during still face procedure at 3 months associated with CU ratings at 36 months (Willoughby, Waschbusch, Moore, & Propper, 2011) Evidence
Implies different biological and parenting underpinnings for CPCU and CP-only children
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
CS- CS+
Con
ditio
ned
Res
pons
e
Controls (n = 274)
Criminals (n = 137)
Crime measured age 23Fear conditioning measures at age 3
CS- = 3 tones not associated with aversive white noiseCS+ = 9 tones associated with aversive noise
Goa, Raine, Venables & Dawson (2010)
Secondary analysis of Durham Child Health and Development Study
178 healthy infants recruited at 3 monthsFollowed through 36 months
Selected subsample based on 36 month behavior ratings completed by parents
CP-only (n = 12)CPCU (n = 7)Controls (n = 10) – demographically matched
Willoughby, Waschbusch, Moore, & Propper (2011)
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Talk Still Face Reunion
% N
egat
ive A
ffec
t
ControlCP-onlyCPCU
Willoughby, Waschbusch, Moore, & Propper (2011)
390
395
400
405
410
415
420
425
430
435
Talk Still Face Reunion
Heart Period (Hi = Low
Arousal)
ControlCP‐onlyCPCU
Willoughby, Waschbusch, Moore, & Propper (2011)
-1.5
-1
-0.5
0
0.5
1
1.5
2
Happiness Irritability Persistence Gross movement
ControlCP-onlyCP/CU
Average research assistant rating following 36 month visit
Willoughby, Waschbusch, Moore, & Propper (2011)
1
2
3
4
5
6
7
Regulation Fear Soothability
ControlCP-onlyCP/CU
CP-only > control > CP/CU
Control > CP-only > CP/CU
Mother temperament ratings at 3 and 6 months (averaged)
Control, CU > CP-only
Willoughby, Waschbusch, Moore, & Propper (2011)
Parenting predicts later CU in child (Waller et al, 2013)
Negative parenting increases CUPositive parenting decreases CU
Child CU predicts later negative parenting (Hawes et al, 2011;
Salihovic et al, 2012)
Parenting Interacts with Child Temperament (Kochanska, 2007)
Fearless children benefit more from positive parenting, which induces effortful controlFearful children benefit more from gentle but assertive discipline
Child antisocial behavior and ineffective parenting may be more highly associated with CP-only versus CP/CU (Cornell & Frick, 2007; Edens et al, 2008; Hipwell et al, 2007; Oxford et al, 2003; Wooten et al, 1997)
Corporal punishment in childhood associated with psychopathy in adulthood only for children with CP-only at baseline (Lynam et al, 2008)
In other words, CP/CU children had stable CU over development, whereas CP-only developed CU as adults only when they experienced corporal punishment
Parenting factors traditionally associated with antisocial behavior not as important for CU kids
0
1
2
3
4
5
6
7
8
9
Good parenting Poor parenting
# of
OD
D/C
D S
ympt
oms
CP-onlyCP/CU
Andershed et al, 2002; Frost, 2006; Hipwell et al, 2007; Oxford et al, 2003; Wooten et al, 1997;
ParticipantsParents and teachers of 796 students ages 5 to 12In BEST school intervention project (Waschbusch et al, 2005)
MeasuresTeacher rated conduct problems = IOWA OD ScaleMom rated CU = Three-item screenerMom rated Parenting = Alabama Parenting Questionnaire
Minus 4 items dropped at school board request
AnalysesPreliminary analyses (Unconditional Mixed Model) showed no effect of classroom/teacher on ratings)Regressions predicting CP from CU, Parenting, CU x Parenting (plus age and sex as covariates)
CU x Involve signif. after age, sex, CU, Pos Inv.R2 = .22; R2change = .004; p < .05
0
0.5
1
1.5
2
2.5
3
Low High
Teache
r Rated
Opp
osition
al Defiance
Parental Involvement
Low CU
High CU
b= ‐0.003 (ns)
b = ‐0.045 (p < .05)
NOTETHE LIMITEDRANGE
Main Effects step significantR2 = .07; R2change = .04; p < .05CU significant: higher CU = higher teacher ODPos Parenting significant but direction of effects is backward
More pos parenting = more teacher ODValidity of self-report of parenting?
CU x Pos Mon signif. after age, sex, CU, parentingR2 = .08; R2change = .006; p < .05
0
0.5
1
1.5
2
2.5
3
Low High
Teache
r Rated
Opp
osition
al Defiance
Poor Monitoring and Supervision
Low CU
High CU
b= 0.02 (ns)
b= 0.11 (p < .05)
CU x Inc Disc signif. after age, gender, CU, parenting
R2 = .08; R2change = .01; p < .05
0
0.5
1
1.5
2
2.5
3
Low High
Teache
r Rated
Opp
osition
al Defiance
Inconsistent Discipline
Low CU
High CU
b= ‐0.04 (p < .05)
b = 0.07 (p < .05)
ParticipantsParents and teachers of 141 students ages 7 to 13Evaluated as part of intake for STP in HalifaxMostly DBD kids, but also some controls
MeasuresMom and Teacher Rated Conduct problems = IOWA OD ScaleMom rated CU = APSDMom rated Parenting = Alabama Parenting Questionnaire
Minus 4 items dropped by accident
AnalysesSame regressions as before except
Age, Sex not used -- non-significant in all preliminary analysesMom OD and Teacher OD used in separate regressions
Interaction step never significantMain Effects Step of Model
All significant: .14 < R2 < .16; p’s < .05CU significant for every model
higher CU = higher teacher OD
Parenting ScalesHigher Poor Monitor & Supervision = More Teacher ODNo other scales significant (Involvement, Pos Parent, Inconsistent Discipline)
CU x Involve signif. after CU, parentingR2 = .87; R2change = .01; p < .05
NOTETHESCALERANGE
0123456789
101112131415
Low High
Mom
Rated
Opp
osition
al Defiant
Parental Involvement
Low CU
Mod CU
High CU
b = ‐.07 (ns)
b = ‐.29 (p < .05)
b = .15 (ns)
CU x Pos Parenting signif. after CU, parentingR2 = .86; R2change = .005; p < .05
0123456789
101112131415
Low High
Mom
Rated
Opp
osition
al Defiant
Positive Parenting
Low CU
Mod CU
High CU
b = .03 (ns)
b = ‐.25 (ns)
b = .31 (p=.07)
Main Effects step significantR2 = .867; R2change = .86; p < .05CU significant: higher CU = higher mom ODMonitoring & Supervision NOT related to Mom OD
Validity of self-report of parenting?
CU x Pos Parenting signif. after CU, parentingR2 = .88; R2change = .01; p < .05
0123456789
101112131415
Low High
Mom
Rated
Opp
osition
al Defiant
Inconsistent Discipline
Low CU
Mod CU
High CU
b = .30 (p < .05)
b = .57 (p < .05)
b = .03 (ns)
Evidence from two samples (clinical and community) that Neg/Ineff parenting & antisocial behavior
Associated as expected for children with CP-onlyNot associated for children with CP/CU; antisocial high regardless of parenting
Consistent with previously published research (Cornell & Frick, 2007; Edens et al, 2008; Hipwell et al, 2007; Oxford et al, 2003; Wooten et al, 1997)
LimitationsSelf-report of parentingResults vary as a function of CP informantDoes not account for parent characteristics (e.g., higher rate of antisocial personality in CP/CU group)
Traditional parenting practices may be less associated with antisocial behavior in CPCU
Fearless temperament = high risk across parenting stylesEvidence mixed
Parenting and CU mutually influentialChild effects: CU induces worse parentingParent effects: Worse parenting induces CU
Are CU Traits real?Are they prevalent enough to care about?Should we study CU?Do CU traits matter?What do we do about them?
Parenting always measured using self reportSelf report has several limitations: (Morsbach & Prinz, 2006)
Accuracy of recall may be poorItems may be unclear or mis-interpretedSocial desirability”Risk of disclosure
No research takes parent’s own characteristics into account
High rates of antisocial in CU kids = less honest or less accurate in self-evaluations?
No experimental evaluations of whether parenting changes linked with CP changes as a function of CUR21 -- address these weaknesses and link PT response to reward sensitivity
Scored but not funded; resubmit in March 2011
Adult psychopathy recalcitrant to treatment (Harris & Rice, 2006; Wong & Hare, 2005)
May get worse in response to some types of treatment (Barbaree, 2005; Rice, Harris, & Cormier, 1992)
Show differential response to contingencies (Dadds & Salmon, 2003; Frick et al, 2001)
Lower physiological arousal in response to distress (Anastassiou-Hadicharalambous & Warden, 2008)In controlled experiments, less likely to learn from punishment, when primed to attend to rewards (O’Brien & Frick; Budhanni et al, 2005)
Speculations that medication may reduce impulsive aggression but increase non-impulsive aggression (Hinshaw & Lee, 2002; Vitiello & Stoff, 1997)
If correct, then standard treatments for conduct problems may be least effective for those most prone to serious, frequent, and violent antisocial behaviors
“Ultimately, the effectiveness of prevention and treatment methods for child and adolescent psychopathy is an empirical question that needs to be investigated”
Farrington, 2005, in a commentary on youth psychopathy
Parent training (PT) is a key intervention for treatment of conduct problems in children
Major component of virtually all empirically supported treatments for CP in kids (Eyberg et al 2008)
Among the most widely used treatment for CP in kids
All have similar procedures and goalsUse principles of behavior therapyIncrease parental attention to positive child behaviorDecrease parental attention to negative behavior
Eleven samples comprising 2,345 youth ages 2 t o 18 yearssmall sample sizes (often < 75)usually clinic referred
9 out of 11 studies (82%) report that pre-treatment CU predicts higher post-treatment CP
Even after controlling for pre-treatment CPNot specific to CD – also apparent in ODDNot specific to informantRobust with respect to parent/family factors
Hawes, Price & Dadds (2014)
24 published studiesMost with adolescents20 of the 24 compared treatment outcomes in CP-only and CPCU18 of the 20 (90%) report worse treatment outcomes for youth with CPCU
Frick et al (2014)
Add treatments to BTStimulant treatmentCognitive / Emotional treatments
Emotional recognition and processing deficitsMoral reasoning deficits
Modify BT to be more effectiveMatch unique learning stylesIndividualizeIntensify
56 Boys ages 4 to 8Met criteria for ODD or CDTreatment = 9 weekly sessions of behavioral PTDependent measures
Home observationsParent ratingsClinical diagnoses
Assessed post-treatment and 6 months later
Hawes & Dadds, 2005; 2007
Post-treatmentCU predicted ODD diagnosis after controlling for ODD and other factorsNot due to treatment implementation (measured using obs and parent report)CU negatively related to TO effectiveness, but not to reward strategies
Parents reported CU kids neither angry nor sad in TO
Hawes & Dadds, 2005; 2007
0102030405060708090
100
Post-Tx Follow Up
% o
f Gro
up
Negative Affect During Time OutStable Low CU
Unstable CU
Hawes & Dadds, 2005; 2007
Boys & girls ages 7-12 yrs with ADHD/CP19 with ADHD/CP-only18 with ADHD/CP-CU
MedicationMethylphenidate (Ritalin®)Evaluated using a within-subjects, randomized, placebo-controlled designDoses
None (placebo) Low Dose (.3 mg/kg) High dose (.6 mg/kg)
Waschbusch, Carrey, Willoughby et al (2007)
Treatment conditionsBmod-onlyBmod + Low DoseBmod + High Dose
Treatment measuresCounselor recorded frequencies of behaviorsAcademic classroom performanceTeacher and counselor IOWA ratings
Inattentive/overactive/impulsive (IO)Oppositional-defiance (OD)
Waschbusch, Carrey, Willoughby et al (2007)
0
1
2
3
4
5
6
BT-only BT-Low BT-High
Aver
age
/ Day
Noncompliance
CP-onlyCP/CU
Waschbusch, Carrey, Willoughby et al (2007)
0
10
20
30
40
50
60
70
80
90
BT-only BT-Low BT-High
Aver
age
/ Day
Rule Violations
CP-onlyCP/CU
Waschbusch, Carrey, Willoughby et al (2007)
0
1
2
3
4
5
6
BT-only BT-Low BT-High
Aver
age
/ Day
Conduct Problems
CP-onlyCP/CU
Waschbusch, Carrey, Willoughby et al (2007)
Same pattern emerged for rule violations and noncompliance
Are results simply a function of severity of CP?
0
1
2
3
4
5
6
BT-only BT-Low BT-High
Lower Baseline ODD/CD
CP-onlyCP/CU
0
1
2
3
4
5
6
BT-only BT-Low BT-High
Higher Baseline ODD/CD
CP-onlyCP/CU
Frequency of Conduct Problems During Treatment
Waschbusch, Carrey, Willoughby et al (2007)
CU group significantly worse response to BT on measures of antisocial behavior
No differences on other measures
Differences diminished when medication added
Differences robust with respect to CP severity
Replicated in one recent study (Blader et al, 2013)
Waschbusch, Carrey, Willoughby et al (2007)
54 Boys & girls ages 7-12 yrs with ADHD/CPSTP participants
38% never medicated62% in a medication assessmentExcluded those always medicated
Outcome MeasuresCounselor improvement ratingsTime out dataEnd of STP sociometrics
Correlations and RegressionsHaas, Waschbusch, Pelham, King, Andrade, & Carrey (2011)
CU at baseline correlated withImprovement ratings of
Social skills (r = -.46)Sports behavior (r = -.33)Problem solving (r = -.55)Overall (r = -.28)
Time outNumber of time outs/day (r = .36)Minutes per time out (r = .29)Negative behaviors during time out (r = .47)
SociometricsPeer like ratings (r = -.28)
Haas, Waschbusch, Pelham, King, Andrade, & Carrey (2011)
CP and CU correlated (r = .64)After controlling for CP, CU associated with
Improvement ratings of Social skills (Beta = -.47)Problem solving (Beta = -.39)
Time outNegative behaviors in time out (Beta = .40)
For several measures, overall regression was significant but neither CP nor CU beta was
Haas, Waschbusch, Pelham, King, Andrade, & Carrey (2011)
When examined alone, CU significantly associated with outcomes in expected ways
Higher CU indicates less positive treatment responseWhen controlling for CP, pattern is attenuated by not entirely accounted forNoteworthy that CU measured using baseline parent ratings, outcomes were not
Not a method effectTruly predictive – CU measured temporally before treatment
Haas, Waschbusch, Pelham, King, Andrade, & Carrey (2011)
Other (unpublished) studiesSRP re-analysis: Bmod x Med (fully crossed)Fabiano study re-analysis: Time out proceduresMRPS 2011MRPS 2012
Secondary analysis of data from a larger study (Pelham et al, in prep)
Boys & Girls Ages 6 to 12 with ADHD/CP21 children with ADHD/CP-only7 Children with ADHD/CP-CU
Treatments Fully crossedBmod: none vs. low vs. highMed: none vs. low vs. med vs. high
Treatment response measured using point system frequency counts
Waschbusch, Willoughby et al ( in prep)
Analyzed using Mixed ModelsResults
BT and MED main effects always significantBehavior therapy and medication work
Group significant for nearly every measureADHD/CP-CU always worse than ADHD/CP-only
Significant BT x Group interactions forConduct problemsNoncomplianceRule violationsComplaining
Med x Group was never significantMedication works equally well for the groups
Waschbusch, Willoughby et al ( in prep)
Waschbusch, Willoughby et al ( in prep)
0
5
10
15
20
25
None Low BT High BT
Aver
age
Per
Day
Conduct Problems
CP-onlyCP/CU
Waschbusch, Willoughby et al ( in prep)
0
10
20
30
40
50
60
70
None Low BT High BT
Average pe
r Day
Rule Violations
CP‐onlyCP/CU
CP/CU more negative in no treatmentCP-only and CP/CU differences were largely due to change from low to high bmod
CP-only improve between low and high BTCP/CU do not (and may get worse)
What might account for this pattern?One difference between low and high bmod was addition of a weekly punisher (chores) for negative behaviorConsistent with lab task data showing punishment less effective or detrimental for CU
Waschbusch, Willoughby et al ( in prep)
If CP/CU do differ in response to bmod, perhaps it is because of response to punishment such as Time Out (Dadds& Salmon, 2003; Frick and Morris, 2007)
Secondary analysis of data from study of different types of Time Out (Fabiano et al, 2004)
Boys & Girls Ages 6 to 12 with ADHD/CP23 children with ADHD/CP-only10 Children with ADHD/CP-CU
Four Time Out conditionsNo time out (response cost only)Short time out (5 minutes)Long time out (15 min)Contingent time out
Waschbusch, Willoughby, Fabiano, et al ( in prep)
Original study Results
Time out more effective than no time outNo differences across type of time out
Used only a single outcome measure – broad measure of antisocial behaviorDid not distinguish based CU
Re-analysis hypothesesCU would be more negative in all time out conditions
More antisocial and punishment averseDifferences would be largest in fixed rather than contingent
Having some reward for behavior would be especially advantageous for the CU group
Waschbusch, Willoughby, Fabiano, et al ( in prep)
0
2
4
6
8
10
12
14
16
18
None Short (5 Min) Long (10 Min) ContingentType of Time Out
InterruptionsCP-onlyCP/CU
Waschbusch, Willoughby, Fabiano, et al ( in prep)
0123456789
10
None Short (5 Min) Long (10 Min) ContingentType of Time Out
Being a Poor SportCP-only
CP/CU
Waschbusch, Willoughby, Fabiano, et al ( in prep)
0
1
2
3
4
5
6
7
None Short (5 Min) Long (10 Min) ContingentType of Time Out
Noncompliance
CP-only
CP/CU
Waschbusch, Willoughby, Fabiano, et al ( in prep)
CP/CU more negative than CP-only in nearly every condition, regardless of time-outShort TO
Best for CP-only worst for CP/CU (sometimes detrimental)CP/CU greater need for “cool down” time?
Contingent TO best for CP/CU worst for CP-onlyCP/CU more response to incentive?More responsive to being given some control?
Waschbusch, Willoughby, Fabiano, et al ( in prep)
CPCU more severe than kids with CP-onlyStimulant medication improved behavior
ADHD or CP rather than CU?Evidence of diminished response to BT?
Selective to BT?Kolko & Pardini, 2012 (eclectic treatment)Hyde et al, 2013 (family intervention)
If BT is less effective, why?
Insensitivity to punishment hypothesized as key component of CU development
Dadds & Salmon, 2003Passive avoidance learning deficit demonstrated in several lab task studies of youth:
Lynam, 1998Frick and colleagues (1996, 2000, 2003)Blair and colleagues (1998, 2001, 2005)
Also over-focus on reward?Reward / punish rarely separated empirically or clinically
“Current treatments may not meet the needs of children with callous-unemotional traits. Specifically, punishment-based approaches may not work optimally. Translational research is needed to develop and evaluate treatments incorporating strict boundaries, consistent rewards, and appeal to self-interest”Moffitt et al, 2008, in a review of high priority research needs for conduct disorder
Purpose: Modify typical BT to meet unique learning style of CPCU kids
Increase reward for non-negative behaviorDecrease punishment (as much as possible) for negative behavior
Funded by R34 grant from NIMHTwo phases
2011: Pilot project with 12 children to develop and try out new behavioral treatment for CU2012: Larger study with 48 children to test feasibility
Within-subjects reversal designA – B – A – C – A – BC – ABaseline – de-emphasize punish – baseline –emphasize reward – baseline – emphasize reward & de-emphasize punish - baseline
N = 11, ages 7 to 11Enrolled in single group that stayed together all summerPrimary purpose was try out procedures
Miller, Haas, Waschbusch et al, 2014
Emphasize rewardSupplemented point system with ticket systemTickets earned throughout week, traded in for toys at end of weekEarned tickets for not demonstrating negative behaviorsExtra rewards in classroom settings
TreatsGame time
Miller, Haas, Waschbusch et al, 2014
De-emphasize punishment2 minute time out vs. 10 minute time outNegative behaviors labeled, but did not result in a point lossDRCs targeted positive behaviors as much as possibleEnd of week reinforcer activity did not have a punishment level
Field trip for high achieversOrdinary day for all others (vs. chores normally for poor achievers0
Miller, Haas, Waschbusch et al, 2014
Conduct ProblemsLow punish bestHi reward worst
Miller, Haas, Waschbusch et al, 2014
Conduct Problems
Miller, Haas, Waschbusch et al (2014)
Huge variability in treatment responseAcross measures & kidsNo different than any other treatment study
There is no substitute for pilot workKids quickly found weak points of treatment and used them to their advantageLack of predictability may be beneficial
N = 48Age: M = 9.3 (range: 7 to 12.6)Sex: 38 boys, 10 girlsIQ: M = 102 (range: 81 to 128)Race: 69% white; 13% African-American; 18% otherEthnicity: 52% Hispanic / LatinoSES: Poverty to Affluent
All with high CU (t-score > 65 on APSD)
Waschbusch, Willoughby, Haas et al, under review
Measure Teacher-only
Parent-only
Parent / Teacher Combined
Symptom CountsADHD-hyper/impulse 6.1 (2.8) 6.6 (2.1) 8.0 (1.4)ADHD-inattention 6.5 (2.8) 6.9 (2.7) 8.3 (1.6)ODD 4.6 (2.8) 4.7 (2.1) 6.5 (1.5)CD 1.6 (1.8) 1.5 (1.9) 2.6 (2.2)
% Meeting CriteriaADHD 83% 82% 98%ODD 71% 77% 54%CD 29% 23% 46%
Waschbusch, Willoughby, Haas et al, under review
Measure Teacher-only
Parent-only
Parent / Teacher Combined
CU Scale ScoresICU total scale sum 40 (11) 34 (11) 48 (9)APSD t-score 73 (11) 78 (10) 73 (6)Dadds sum 11 (4) 7 (3) 12 (3)CPS CU Scale 3 (2) 2 (1) 4 (1)
CU GroupsAPSD 10% 91% 94% 94%APSD 5% 89% 79% 90%
Waschbusch, Willoughby, Haas et al, under review
Conducted in the STP4 groups of 12 kids
Within-subjects treatment manipulation4 weeks of standard STP4 weeks of modified STPOrder counter-balanced across groups
Two treatmentsStandard STP – balanced reward and punishModified STP – increase reward, decrease punish
Waschbusch, Willoughby, Haas et al, under review
Component Standard ModifiedPoint System Earn points for positive and lack of
negative behaviorsEarn points for positive and lack of
negative behaviors
Lose points for negative behaviors Do NOT lose points for negative behaviors
Morning Module Awards for HPK, Most Improved Awards for HPK, Most Improved
Award for Best Social Skill Award for Best Helper
Social Skill Review Emotion Skill Review
Daily Check In None Counselor‐initiated brief positive encounter with each child
Sit‐Out Cards None Three “I need a 5 minute break” cards per day
Waschbusch, Willoughby, Haas et al, in prep
Component Standard ModifiedTime Out Starts at 10 minutes Starts at 10 minutes
Can escalate to 20 minutes Can be reduced to 5 minutes
DRC Standardized goals Standardized goals
Reward high performance Reward high performance
Punish poor performance Do NOT punish poor performance
Daily reinforce Reward high performance Reward high performance
Punish poor performance Do NOT punish poor performance
Standard sport (BB, Softball, Soccer) at end of each day
Chance to earn a fun game at end of each day
Weekly reinforce Reward high performance Reward high performance
Punish poor performance Do NOT punish poor performance
Waschbusch, Willoughby, Haas et al, under review
Mixed ModelsTreatment as predictorWeek, Sex, Medication as covariates
Outcomes: Composite STP categoriesParent, counselor ratings
Transformed data to reduce skewResults robust with respect to extreme cases
Waschbusch, Willoughby, Haas et al, under review
Max weekly average during treatment:44.5 Time Outs per day22 Minutes per day in physical management103 Conduct Problems per day
About 1 SD higher than BT-only group in Pelham et al (2000) – MTA sample
Waschbusch, Willoughby, Haas et al, under review
Point System Category Effect Size NotesConduct problems 0.29* Less conduct problems in SBT than MBTNegative verbalizations 0.15+ Less negative verbals in SBT than MBTComplaining 0.11Interruption 0.10Noncompliance 0.11Rule violations 0.23* Less rule violations in SBT than MBTPositive peer behaviors 0.53* More positive with peers in MBT than SBTMinutes in Time Out -0.03Number of Time Out 0.25* Fewer Time Outs in SBT than MBTMinutes physical management 0.08
Waschbusch, Willoughby, Haas et al, under review
Red font = better in modified than standard treatment* = p < .05 + = p < .10
Parent Rating Scale Effect Size NotesInattentive-Overactive 0.13Oppositional-Defiant -0.45* Less oppositional in MBT than SBTSerious conduct problems -0.24* Less conduct problems in MBT than SBTRule following problems -0.37* Less rule following problems in MBT than SBTOverall problems -0.11
Waschbusch, Willoughby, Haas et al, under review
Red font = better in modified than standard treatment* = p < .05 + = p < .10
26%
23%34%
17%
Which Treatment Worked Best for This Child?
Standard BestModified BestBoth EffectiveNeither Effective
Conduct Problems Negative Verbalization
SBT reduced negative behaviors on objective measures
MBT Increased positive behaviors on objective measuresImproved behavior on parent subjective ratingsSlightly higher parent satisfaction
Individual differences in treatment responseAbout 83% judged as positive treatment respondersTreatment responders equally divided between
MBT BestSBT BestBoth worked well
Waschbusch, Willoughby, Haas et al, under review
InterpretationsKids with CU perfectly happy to turn on the positives if in their best interest (increased reward)?But will take advantage if punishment decreasesParent view of MBT advantages may be
Related to increased reward for their childImportant – start of virtuous cycle?
Waschbusch, Willoughby, Haas et al, under review
Hypothesis 1: Perhaps there’s a treatment response that we did not detect (yet)
No controls = do not really know “true” responseMany other measures yet to examine, some that look promising
Hypothesis 2: Behavior – Consequence consistency or salience as unintended confound
Not entirely accurate that children with CU respond poorly to punishmentRather, respond poorly to punishment under certain conditions
If a behavior is always rewarded and never punished, CU and non-CU equally able to change in response to stimuliIf a behavior is sometimes rewarded and sometimes punished, CU less able than non-CU to change in response to stimuli
Arguably best analogue to “real life”
Budhani & Blair, 2005
Hypothesis 2 (Cont.): Standard Treatment
Followed “best practice” for BT and emphasized:
Consistency in defining behavior and consequenceConsistency in applying definitions
Modified TreatmentInadvertently downplayed consistency
Labeling most misbehavior without applying consequence until it gets really serious arguably put kids in the “gray area”
Hypothesis 3: Lab tasks do not translate to clinical practice
Does punishment actually decrease performance / behavior in CU kids, or simply not help them as much?What do we mean by punishment?
Loss of something positive?Application of something negative?
Past research may underestimate effects of BT for children with CP-onlyImportant to assess CU in children with CP
CU traits common among children with CPNormally distributed within CP children
CPCU and CP-only differ in many important waysSuggests different etiological pathways
Children with CU traits seem to show a less positive response to behavior therapy
Reported in two independent, recent reviewsLess positive response does not mean lack of response
BT as necessary but not sufficient treatment
Promising treatment approachesIndividualized psychosocial treatments
Kolko & Pardini (2010)Supplementing BT with other approaches
Dadds et al (2012): Emotion recognition supplement to PT
Stimulant medicationWaschbusch et al (2007)Blader et al (2013)
PreventionHyde, Shaw et al (2011) – prevention approach
What do CU kids look like in “real life” settings – in school, with their peers, etc.?How do we best assess CU traits?
Optimal informant unclearParent, teachers don’t directly observe guiltChildren may be prone to dishonesty / deceit
Optimal method unclearExclusively ratings (but interview work beginning)
Inventory of Callous Unemotional (ICU) most used scaleRole of bias (halo effects, social desirability, etc.)
Lack of normative informationUnclear if dimensional vs. categorical conceptualization best fit
Why does stimulant medication work?Is med improving non-impulsively driven antisocial behaviors?Is medication acting through a different pathway in children with CU?
What’s the role of anger and impulsivity in CU?What’s the role of punishment
harm vs. not help CU kids?Add aversive vs. Take away positive?
What is role of parenting in CU?Can methodology account for extant findings?Are “non-traditional” parenting factors related?Do we need to look earlier in life?If not parenting, then what else?
What supplemental treatments should be tried?Moral reasoning?Guilt induction?Empathy improvement?
What is the role of manipulation in treatment?Setting clear limits vs. inducing a power struggleUse child’s need for control to advantage?Appeal to child’s self-interest
Contact info:Dan WaschbuschEmail: [email protected]