Daniel A. Waschbusch, Ph.D.

Penn State Hershey Medical Center Department of Psychiatry Florida International University Center for Children and Families Department of Psychology Funding to Waschbusch Collaborators Mike Willoughby from NIMH, SSHRC, Bill Pelham NSHRF, IWK health Sarah Haas center, CIBC miracle Norm Carrey network, Dalhousie Greg Fabiano Jim Waxmonsky University, Lisa Burrows-MacLean Sara King Brendan Andrade Disclosures: Andrew Greiner JACP editing stipend Beth Gnagy Past funding from drug Omar Kazmi Kerry Roach companies but not for any Many undergrad RAs of this work Counselors in the STP Kids 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 prevalent

5% 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 categories Oppositional Defiant Disorder Negative, hostile, argumentative behavior Conduct Disorder Aggression to people and animals Destruction of property Deceitfulness or theft Serious rule violations (e.g., truancy, running away) Both categories also require Patterns of behavior Serious impairment Exceed 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 pathways Matching intervention to need Lower cost Better outcomes Childhood onset Emerge before age 10 to 12 Associated with with numerous dispositional and contextual risk factors Adolescent onset Emerge after age 10 to 12 Associated with contextual risk factors

Supported by decades of research (Robbins, 1970’s; Moffitt, 1993, 2003; Loeber, 1988) Childhood Onset Adolescent Onset Family dysfunction Rebellious Low verbal IQ Reject social norms / hierarchies Negative / Ineffective parenting Affiliate with deviant peers Deviant social cognition Low parental monitoring / supervision Peer / Social rejection Inattention Poor impulse control

Moffitt, 1993, 2003; Loeber, 1988; many others Not all child-onset cases have poor outcomes

50% persist, 50% desist (Loeber, 1982; Olweus, 1982) Not all adolescent-onset cases desist Can 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 desists Adolescent onset that persists or desists Adult onset that persists of desists 0.8 None 0.7 Child onset persist 0.6 Child onset desist 0.5 Adol onset 0.4 0.3 0.2 0.1 Probability of Serious Violence of Serious Probability 0 13 14 15 16 17 18 19 20 21 22 23 24 25

Age

Loeber, Farrington, Stouthamer-Loeber & White, 2008 8 None (56%) 7 Child onset persist (10%) 6 Child onset desist (8%) 5 Adol onset (26%) 4

Average # Average 3 2 1 0 Variety Number Official Convictions at Age 26

Moffitt, Caspi, Harrington, & Milne (2002) 35 None (46%) 30 Child onset persist (11%) 25 Child onset desist (24%) 20 Adol onset (20%) 15

% of Group 10 5 0 Self reported violence Violence conviction Violence at Age 32

Odgers, Moffitt et al (2008) 35 None (46%) 30 Child onset persist (11%) 25 Child onset desist (24%) 20 Adol onset (20%) 15 % of Group 10

5

0 Psychiatric Disorder Mental Health Impairment

Odgers et al (2007) 70 None (46%) 60 Child onset persist (11%) 50 Child onset desist (24%) 40 Adol onset (20%) 30 % of Group 20

10

0 Good / Excellent Health Hospitalized Past Year

Odgers et al (2007) 6 None (46%) 5 Child onset persist (11%)

4 Child onset desist (24%) Adol onset (20%) 3

2

Average # in Past Year # in Past Average 1

0 # GP visits Physical health problems

Odgers et al (2007) Different pathways to antisocial behavior Childhood onset = greatest persistence and severity But also differences within child-onset Persistently antisocial vs. desist over development Suggests need to differentiate within child-onset Callous-Unemotional traits may be a useful construct for this purpose Evidence throughout history, even in ancient times E.g., Nero Poisoned his stepbrother Murdered his mother Kicked his 2nd wife to death when she was pregnant Burned 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, antisocial Seemed 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 health Became foundation of all subsequent work David Lykken (1957) First empirical test of Cleckley’s conceptualization First evidence for several constructs that remain central to understanding psychopathy Passive avoidance deficit (deficient learning from punishment ) Decreased skin response to punishment Decreased anxiety Bob Hare (1970s and 1980s) Developed the Pscyhopathy Checklist (PCL) and PCL-R to operationalize Cleckley’s criteria Propelled an enormous amount of psychopathy research Currently most prominent psychopathy researcher Deficient affective experience Lack of remorse or guilt Shallow affect Callous / lack of empathy Arrogant and deceitful interpersonal style Superficial charm Conning / manipulative Pathological lying Irresponsible and impulsive lifestyle Lack of long term goals Failure to accept responsibility for own actions Parasitic 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 homicide 34 psychopaths, 91 non-psychopaths Compared characteristics of the homicides Murders perpetrated by psychopaths: Almost twice as likely to be instrumental Less 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 wrong Lack of empathy or concern for others (callous) Unconcerned about own performance Shallow or deficient affect Modifier of conduct disorder in DSM-V limited 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? “Isn’t CU really just a marker for impairment?” – me, repeatedly, 1999 or so Antisocial Process Screening Device – CU Scale:

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 How does APSD perform when you divide the “impairment” vs. CU items? Clinical sample Halifax Summer Treatment Program intakes 2001- 2003 Parent and teacher ratings on about 180 children APSD Disruptive Behavior Disorder - ADHD, ODD, CD Impairment Rating Scale React/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 sample BEST Project: Elementary school intervention implemented in six schools Parent and teacher ratings on about 1550 children at baseline Measures CU Screening measure Three items generated by psychopathy experts: Lacks remorse Seems to enjoy being mean Is 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 2014 Two 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 impairment Anecdotal 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 settings

20% of adolescent offenders (Lindberg, 2009; Salekin, 2004)

Community settings (Rowe, Maughan et al, 2010) 1% CD/CU 1% CD-only 3% CU-only Clinical settings Most 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 Clinic Sample 100.0 100.0

90.0 87.3 Boys (n = 806) 90.0 Boys (n = 78.7 141) 80.0 Girls (n = 741) 80.0

70.0 70.0

60.0 60.0 52.5 50.0 50.0 % of Sex % of % of Sex % of 40.0 40.0 31.2 30.0 30.0 27.0 25.5 22.5 20.0 15.9 20.0 15.0 16.3 10.3 10.0 10.0 4.1 10.0 2.0 1.4 0.4 0.0 0.0 Not at all Just a little Pretty Very much Not at all Just a little Pretty Very much much much

Waschbusch et al; 2005 Waschbusch et al; 2007 Sex

25 Boys (n = 144) 20 Girls (n = 41)

15

10 % of Sample

5

0 30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 T-Score from the APSD CU Scale

Waschbusch et al; 2007 – STP 2001 - 2003 Non-CP

25 Not CP (n=56) 20

15

10 % of Sample

5

0 30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 T-Score from the APSD CU Scale

Waschbusch et al; 2007 – STP 2001 - 2003 ODD

35

30 ODD (n = 62) 25

20

15 % of Sample 10

5

0 30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 T-Score from the APSD CU Scale

Waschbusch et al; 2007 – STP 2001 - 2003 CD

35

30 CD (n = 65) 25

20

15 % of Sample 10

5

0 30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 T-Score from the APSD CU Scale

Waschbusch et al; 2007 – STP 2001 - 2003 Diagnosis

35 Not CP (n=56) 30 ODD (n = 62) 25 CD (n = 65)

20

15 % of Sample 10

5

0 30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 T-Score from the APSD CU Scale

Waschbusch et al; 2007 – STP 2001 - 2003 None CU None CU 0.2 100.0 100.0 2.0 13.9 90.0 90.0 28.3 80.0 80.0 46.6 70.0 70.0 75.4 60.0 60.0 50.0 99.8 50.0 98.0 86.1 40.0 40.0 % of Sample % of

% of Sample % of 71.7 30.0 30.0 53.4 20.0 20.0 10.0 10.0 24.6 0.0 0.0 None ODD CD None ODD CD Community Sample Clinic Sample Waschbusch et al; 2005 Waschbusch et al; 2007 Informant

45 40 Teacher (n = 143)

35 Parent (n = 165) 30 25 20

% of Sample 15 10 5 0 0 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 70 to 72 Total Score from the ICU

Waschbusch & Pelham – STP 2011-2012 CU Traits are not uncommon 4% of normal population 1 kid in every classroom Normally 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 versions Pros Six items – easy and fast Factor structure, validity, test-retest reliability well supported Published norms Widely used – default measure of CU in kids Cons Low alphas in some studies Only six items -- Other measures – promising, but not established Inventory 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”? Risks Highly negative connotation; stigmatizing Comes out of psychopathy research Often viewed as a stable, untreatable condition

The risks can be mitigated Education about developmental and individual differences Careful 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 control Little regard for how own behavior affects others Will exploit others to get what they want Quickly become bored Need constant attention and validation Egocentric Benefits May 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: Determination Curiosity Insensitivity 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 Psychopaths Jennifer 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 Psychopaths Michael 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 real Have high potential to stigmatize Also high potential to identify kids who need help Do 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 sample 30% to 50% in clinic referred CP sample May be normally distributed in clinic samples Non-overlapping with ODD/CD 25% to 50% of ODD/CD in community sample 50% to 75% of ODD/CD in clinical sample More prevalent in boys than girls Other research suggests there may be different etiological underpinnings as well (Dadds et al 2009; Fontaine et al, 2010) 120

100

80

60

40

Number of Publications of Number 20

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Publication Year

Salekin & Lynam (2010) – estimated from fig 1.1 Frick et al (2014) – review in Psyc Bull 269 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 Development

Less 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 Processing

Less 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 abilities Less 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 common Play 100 cards First 10 cards: all reward no point loss Next 10 cards: 9 reward, 1 point loss Next 10 cards: 8 reward, 2 point loss Etc. DV = how many cards will kids play until they stop? 350 a 300 b 250 b

200

150

# of Cars Played 100

50

0 Non-Anxious CU Anxious CU Controls

O’Brien & Frick, 1996 350 b 300

a a 250 a

200 Clinic Control ADHD-only 150 # of Trials # of ADHD/CP-only 100 ADHD/CP-CU

50

0 Group Barry et al, 2000 Biology

Less 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 (Raine et al, 2005; Amastassiou-Hadjicharalmbous & Warden, 2008) Lower salivary cortisol but no differences on testosterone (Loney et al, 2006)

Frick et al (2014) Co-Occurring problems

Lower 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 Studies Genetics account for 42% to 68% of CU 2-3 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) CP-only CP/CU

Genetics Genetics

36 30 36 Shared Shared environment 0 environment 81 34 Nonshared Nonshared environment environment

Viding et al (2005) Social Cognition

Accurately 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 1.3 1.25 1.2 1.15 1.1 Control 1.05 CU-only 1 CP-only 0.95 CP/CU 0.9 0.85 0.8 Overtly aggressive Prosocial Type of Solution

Waschbusch, Walsh et al (2007) Antisocial Behavior CPCU 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) 70 Control 60 CU‐only 50 CP‐only CP/CU 40 Group

of

30 % 20

10

0 Any Violence Status Type of Delinquent Act

Frick, Cornell et al (2003) 60 Participants 32 Controls 14 with CP-only 14 with CP/CU Competed in reaction time task Wins and losses fixed ahead of time Standardized provocations (low or high) from a “peer” No real peer – actually a computer Two aggression conditions Instrumental 0 to 10 points “It will make it harder for him/her to win the game” Hostile: 0 to 10 seconds of white noice 0 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 them Low 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 them Sent a consequence to “opponent” Instrumental aggression: 0 to 10 points Hostile aggression: 0 to 10 seconds of white noise burst Sent a message to opponent Only presenting instrumental condition Most consistent with past research Results similar across conditions Both conditions get complex and messy in presentation format

Helseth, Waschbusch et al, under review Behavior 10 Control 9 b CP-only 8 CP/CU 7 a a 6 5

Aggression 4 3 2 1 0 Affect 4 Control 3.5 CP-only CP/CU 3

2.5

2 Anger 1.5

1

0.5

0 Behavior 10 Control 9 CP-only 8 b CP/CU 7 6 a 5 a 4 Aggression 3 2 1 0 Low High Level of Provocation Affect 4 Control 3.5 CP-only 3 CP/CU 2.5

2 Anger 1.5

1

0.5

0 Low High Level of Provocation Behavior 10 Control 9 CP-only 8 CP/CU 7 6 Highly Provoked 5 By “Opponent” 4 Aggression 3 2 1 0 123456 Final Trials of Task Affect 4 Control 3.5 Highly Provoked By “Opponent” CP-only 3 CP/CU 2.5

2 Anger 1.5

1

0.5

0 123456 Final Trials of Task Under-regulated pathway – ADHD/CP-only Difficult temperament impulsive, quick to anger, reactive Interacts with ineffective parenting harsh, inconsistent discipline, poor monitoring and supervision, low positives, etc. Under-arousal pathway – ADHD/CP-CU Low physiological arousal in response to: Punishment / parent socialization Other’s distress Evidence Physiological 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 0.08 Crime measured age 23 0.07 Fear conditioning 0.06 measures at age 3 0.05 CS- = 3 tones not associated with aversive 0.04 white noise 0.03 Controls (n = 274) CS+ = 9 tones associated 0.02 Criminals (n = 137) with aversive noise Conditioned Response 0.01 0 CS- CS+

Goa, Raine, Venables & Dawson (2010) Secondary analysis of Durham Child Health and Development Study 178 healthy infants recruited at 3 months Followed 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) 0.35

0.3

0.25

0.2 Control CP-only 0.15 CPCU

% Negative Affect % Negative 0.1

0.05

0 Talk Still Face Reunion

Willoughby, Waschbusch, Moore, & Propper (2011) 435 430 425 Arousal) 420 Low

= 415 Control

(Hi CP‐only 410 405 CPCU Period 400

Heart 395 390 Talk Still Face Reunion

Willoughby, Waschbusch, Moore, & Propper (2011) Average research assistant rating following 36 month visit

2 1.5 1

0.5 Control 0 CP-only CP/CU -0.5 -1 -1.5 Happiness Irritability Persistence Gross movement

Willoughby, Waschbusch, Moore, & Propper (2011) Mother temperament ratings at 3 and 6 months (averaged)

7 Control, CU > CP-only Control > CP-only > CP/CU 6

5 Control 4 CP-only > control > CP/CU CP-only 3 CP/CU

2

1 Regulation Fear Soothability

Willoughby, Waschbusch, Moore, & Propper (2011) Parenting predicts later CU in child (Waller et al, 2013) Negative parenting increases CU Positive 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 control Fearful 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 9 8 7 6 5 CP-only 4 CP/CU 3 2 # of ODD/CD Symptoms 1 0 Good parenting Poor parenting

Andershed et al, 2002; Frost, 2006; Hipwell et al, 2007; Oxford et al, 2003; Wooten et al, 1997; Participants Parents and teachers of 796 students ages 5 to 12 In BEST school intervention project (Waschbusch et al, 2005) Measures Teacher rated conduct problems = IOWA OD Scale Mom rated CU = Three-item screener Mom rated Parenting = Alabama Parenting Questionnaire Minus 4 items dropped at school board request Analyses Preliminary 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

3

2.5 Defiance

2 b= ‐0.003 (ns)

NOTE 1.5 THE Low CU Oppositional 1 b= ‐0.045 (p < .05) LIMITED High CU

RANGE Rated 0.5

Teacher 0 Low High

Parental Involvement Main Effects step significant R2 = .07; R2change = .04; p < .05 CU significant: higher CU = higher teacher OD Pos Parenting significant but direction of effects is backward More pos parenting = more teacher OD Validity of self-report of parenting? CU x Pos Mon signif. after age, sex, CU, parenting R2 = .08; R2change = .006; p < .05

3

2.5 Defiance

2 b= 0.02 (ns)

1.5 Low CU Oppositional 1 b= 0.11 (p < .05) High CU Rated 0.5

Teacher 0 Low High

Poor Monitoring and Supervision CU x Inc Disc signif. after age, gender, CU, parenting R2 = .08; R2change = .01; p < .05

3

2.5 Defiance

2 b= ‐0.04 (p < .05)

1.5 Low CU Oppositional 1 b= 0.07 (p < .05) High CU Rated 0.5

Teacher 0 Low High

Inconsistent Discipline Participants Parents and teachers of 141 students ages 7 to 13 Evaluated as part of intake for STP in Halifax Mostly DBD kids, but also some controls Measures Mom and Teacher Rated Conduct problems = IOWA OD Scale Mom rated CU = APSD Mom rated Parenting = Alabama Parenting Questionnaire Minus 4 items dropped by accident Analyses Same regressions as before except Age, Sex not used -- non-significant in all preliminary analyses Mom OD and Teacher OD used in separate regressions Interaction step never significant Main Effects Step of Model All significant: .14 < R2 < .16; p’s < .05 CU significant for every model higher CU = higher teacher OD Parenting Scales Higher Poor Monitor & Supervision = More Teacher OD No other scales significant (Involvement, Pos Parent, Inconsistent Discipline) CU x Involve signif. after CU, parenting R2 = .87; R2change = .01; p < .05

15 14 13 b = .15 (ns) 12 11 Defiant 10 b = ‐.07 (ns) 9 NOTE 8 7 Low CU Oppositional

THE 6 b = ‐.29 (p < .05) Mod CU SCALE 5

Rated High CU

RANGE 4

Mom 3 2 1 0 Low High

Parental Involvement CU x Pos Parenting signif. after CU, parenting R2 = .86; R2change = .005; p < .05

15 14 13 b = .31 (p=.07) 12 11 Defiant

10 9 b = .03 (ns) 8 7 Low CU

Oppositional b = ‐.25 (ns) 6 Mod CU 5

Rated High CU

4

Mom 3 2 1 0 Low High

Positive Parenting Main Effects step significant R2 = .867; R2change = .86; p < .05 CU significant: higher CU = higher mom OD Monitoring & Supervision NOT related to Mom OD Validity of self-report of parenting? CU x Pos Parenting signif. after CU, parenting R2 = .88; R2change = .01; p < .05

15 14 13 b = .03 (ns) 12 11 Defiant 10 b = .30 (p < .05) 9 8 7 Low CU Oppositional 6 Mod CU 5

Rated High CU

4 b = .57 (p < .05) Mom 3 2 1 0 Low High

Inconsistent Discipline Evidence from two samples (clinical and community) that Neg/Ineff parenting & antisocial behavior Associated as expected for children with CP-only Not 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) Limitations Self-report of parenting Results vary as a function of CP informant Does 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 styles Evidence mixed Parenting and CU mutually influential Child effects: CU induces worse parenting Parent 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 report

Self report has several limitations: (Morsbach & Prinz, 2006) Accuracy of recall may be poor Items may be unclear or mis-interpreted Social 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 CU R21 -- 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 goals Use principles of behavior therapy Increase parental attention to positive child behavior Decrease parental attention to negative behavior Eleven samples comprising 2,345 youth ages 2 t o 18 years small 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 CP Not specific to CD – also apparent in ODD Not specific to informant Robust with respect to parent/family factors

Hawes, Price & Dadds (2014) 24 published studies Most with adolescents 20 of the 24 compared treatment outcomes in CP- only and CPCU 18 of the 20 (90%) report worse treatment outcomes for youth with CPCU

Frick et al (2014) Add treatments to BT Stimulant treatment Cognitive / Emotional treatments Emotional recognition and processing deficits Moral reasoning deficits Modify BT to be more effective Match unique learning styles Individualize Intensify 56 Boys ages 4 to 8 Met criteria for ODD or CD Treatment = 9 weekly sessions of behavioral PT Dependent measures Home observations Parent ratings Clinical diagnoses Assessed post-treatment and 6 months later

Hawes & Dadds, 2005; 2007 Post-treatment CU predicted ODD diagnosis after controlling for ODD and other factors Not 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 Negative Affect During Time Out 100 Stable Low CU 90 80 Unstable CU 70 60 50 40 % of Group 30 20 10 0 Post-Tx Follow Up

Hawes & Dadds, 2005; 2007 Boys & girls ages 7-12 yrs with ADHD/CP 19 with ADHD/CP-only 18 with ADHD/CP-CU Medication Methylphenidate (Ritalin®) Evaluated using a within-subjects, randomized, placebo- controlled design Doses None (placebo) Low Dose (.3 mg/kg) High dose (.6 mg/kg)

Waschbusch, Carrey, Willoughby et al (2007) Treatment conditions Bmod-only Bmod + Low Dose Bmod + High Dose Treatment measures Counselor recorded frequencies of behaviors Academic classroom performance Teacher and counselor IOWA ratings Inattentive/overactive/impulsive (IO) Oppositional-defiance (OD)

Waschbusch, Carrey, Willoughby et al (2007) Noncompliance 6 CP-only 5 CP/CU 4

3

Average / Day Average 2

1

0 BT-only BT-Low BT-High

Waschbusch, Carrey, Willoughby et al (2007) Rule Violations 90 80 CP-only 70 CP/CU 60 50 40

Average / Day Average 30 20 10 0 BT-only BT-Low BT-High

Waschbusch, Carrey, Willoughby et al (2007) Conduct Problems 6 CP-only 5 CP/CU 4

3

Average / Day Average 2

1

0 BT-only BT-Low BT-High Same pattern emerged for rule violations and noncompliance

Waschbusch, Carrey, Willoughby et al (2007) Are results simply a function of severity of CP?

6 Lower Baseline ODD/CD 6 Higher Baseline ODD/CD 5 5

4 4 CP-only CP-only 3 CP/CU 3 CP/CU 2 2

1 1

0 0 BT-only BT-Low BT-High BT-only BT-Low BT-High

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/CP STP participants 38% never medicated 62% in a medication assessment Excluded those always medicated Outcome Measures Counselor improvement ratings Time out data End of STP sociometrics Correlations and Regressions

Haas, Waschbusch, Pelham, King, Andrade, & Carrey (2011) CU at baseline correlated with Improvement ratings of Social skills (r = -.46) Sports behavior (r = -.33) Problem solving (r = -.55) Overall (r = -.28) Time out Number of time outs/day (r = .36) Minutes per time out (r = .29) Negative behaviors during time out (r = .47) Sociometrics Peer 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 out Negative 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 response When controlling for CP, pattern is attenuated by not entirely accounted for Noteworthy that CU measured using baseline parent ratings, outcomes were not Not a method effect Truly predictive – CU measured temporally before treatment

Haas, Waschbusch, Pelham, King, Andrade, & Carrey (2011) Other (unpublished) studies SRP re-analysis: Bmod x Med (fully crossed) Fabiano study re-analysis: Time out procedures MRPS 2011 MRPS 2012 Secondary analysis of data from a larger study (Pelham et al, in prep) Boys & Girls Ages 6 to 12 with ADHD/CP 21 children with ADHD/CP-only 7 Children with ADHD/CP-CU Treatments Fully crossed Bmod: none vs. low vs. high Med: none vs. low vs. med vs. high Treatment response measured using point system frequency counts

Waschbusch, Willoughby et al ( in prep) Analyzed using Mixed Models Results BT and MED main effects always significant Behavior therapy and medication work Group significant for nearly every measure ADHD/CP-CU always worse than ADHD/CP-only Significant BT x Group interactions for Conduct problems Noncompliance Rule violations Complaining Med x Group was never significant Medication works equally well for the groups

Waschbusch, Willoughby et al ( in prep) Conduct Problems 25

20 CP-only 15 CP/CU

10 Average Per Day Per Average 5

0 None Low BT High BT

Waschbusch, Willoughby et al ( in prep) Rule Violations 70

60

50 Day 40 per CP‐only 30 CP/CU

Average 20

10

0 None Low BT High BT

Waschbusch, Willoughby et al ( in prep) CP/CU more negative in no treatment CP-only and CP/CU differences were largely due to change from low to high bmod CP-only improve between low and high BT CP/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 behavior Consistent 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/CP 23 children with ADHD/CP-only 10 Children with ADHD/CP-CU Four Time Out conditions No 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 out No differences across type of time out Used only a single outcome measure – broad measure of antisocial behavior Did not distinguish based CU Re-analysis hypotheses CU would be more negative in all time out conditions More antisocial and punishment averse Differences 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) 18 Interruptions 16 CP-only 14 CP/CU 12 10 8 6 4 2 0 None Short (5 Min) Long (10 Min) Contingent Type of Time Out

Waschbusch, Willoughby, Fabiano, et al ( in prep) 10 Being a Poor Sport CP-only 9 8 CP/CU 7 6 5 4 3 2 1 0 None Short (5 Min) Long (10 Min) Contingent Type of Time Out

Waschbusch, Willoughby, Fabiano, et al ( in prep) 7 Noncompliance 6 CP-only 5 CP/CU 4

3

2

1

0 None Short (5 Min) Long (10 Min) Contingent Type of Time Out

Waschbusch, Willoughby, Fabiano, et al ( in prep) CP/CU more negative than CP-only in nearly every condition, regardless of time-out Short 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-only CP/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-only Stimulant 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, 2003 Passive avoidance learning deficit demonstrated in several lab task studies of youth: Lynam, 1998 Frick 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 behavior Decrease punishment (as much as possible) for negative behavior Funded by R34 grant from NIMH Two phases 2011: Pilot project with 12 children to develop and try out new behavioral treatment for CU 2012: Larger study with 48 children to test feasibility Within-subjects reversal design A –B –A –C –A–BC –A Baseline – de-emphasize punish – baseline – emphasize reward – baseline – emphasize reward & de-emphasize punish - baseline N = 11, ages 7 to 11 Enrolled in single group that stayed together all summer Primary purpose was try out procedures

Miller, Haas, Waschbusch et al, 2014 Emphasize reward Supplemented point system with ticket system Tickets earned throughout week, traded in for toys at end of week Earned tickets for not demonstrating negative behaviors Extra rewards in classroom settings Treats Game time

Miller, Haas, Waschbusch et al, 2014 De-emphasize punishment 2 minute time out vs. 10 minute time out Negative behaviors labeled, but did not result in a point loss DRCs targeted positive behaviors as much as possible End of week reinforcer activity did not have a punishment level Field trip for high achievers Ordinary day for all others (vs. chores normally for poor achievers0

Miller, Haas, Waschbusch et al, 2014 Conduct Problems

Low punish best Hi reward worst

Miller, Haas, Waschbusch et al, 2014 Conduct Problems

Miller, Haas, Waschbusch et al (2014) Huge variability in treatment response Across measures & kids No different than any other treatment study There is no substitute for pilot work Kids quickly found weak points of treatment and used them to their advantage Lack of predictability may be beneficial N = 48 Age: M = 9.3 (range: 7 to 12.6) Sex: 38 boys, 10 girls IQ: M = 102 (range: 81 to 128) Race: 69% white; 13% African-American; 18% other Ethnicity: 52% Hispanic / Latino SES: Poverty to Affluent All with high CU (t-score > 65 on APSD)

Waschbusch, Willoughby, Haas et al, under review Measure Teacher- Parent- Parent / Teacher only only Combined Symptom Counts ADHD-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 Criteria ADHD 83% 82% 98% ODD 71% 77% 54% CD 29% 23% 46%

Waschbusch, Willoughby, Haas et al, under review Measure Teacher- Parent- Parent / Teacher only only Combined CU Scale Scores ICU 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 Groups APSD 10% 91% 94% 94% APSD 5% 89% 79% 90%

Waschbusch, Willoughby, Haas et al, under review Conducted in the STP 4 groups of 12 kids Within-subjects treatment manipulation 4 weeks of standard STP 4 weeks of modified STP Order counter-balanced across groups Two treatments Standard STP – balanced reward and punish Modified STP – increase reward, decrease punish

Waschbusch, Willoughby, Haas et al, under review Component Standard Modified Point System Earn points for positive and lack of Earn points for positive and lack of negative behaviors 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 Modified Time 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) Chance to earn a fun game at end of at end of each day 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 Models Treatment as predictor Week, Sex, Medication as covariates Outcomes: Composite STP categories Parent, counselor ratings Transformed data to reduce skew Results robust with respect to extreme cases

Waschbusch, Willoughby, Haas et al, under review Max weekly average during treatment: 44.5 Time Outs per day 22 Minutes per day in physical management 103 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 Notes Conduct problems 0.29* Less conduct problems in SBT than MBT Negative verbalizations 0.15+ Less negative verbals in SBT than MBT Complaining 0.11 Interruption 0.10 Noncompliance 0.11 Rule violations 0.23* Less rule violations in SBT than MBT Positive peer behaviors 0.53* More positive with peers in MBT than SBT Minutes in Time Out -0.03 Number of Time Out 0.25* Fewer Time Outs in SBT than MBT Minutes physical management 0.08

Red font = better in modified than standard treatment * = p < .05 + = p < .10

Waschbusch, Willoughby, Haas et al, under review Parent Rating Scale Effect Size Notes Inattentive-Overactive 0.13 Oppositional-Defiant -0.45* Less oppositional in MBT than SBT Serious conduct problems -0.24* Less conduct problems in MBT than SBT Rule following problems -0.37* Less rule following problems in MBT than SBT Overall problems -0.11

Red font = better in modified than standard treatment * = p < .05 + = p < .10

Waschbusch, Willoughby, Haas et al, under review Which Treatment Worked Best for This Child?

17% 26%

Standard Best Modified Best 34% 23% Both Effective Neither Effective Conduct Problems Negative Verbalization SBT reduced negative behaviors on objective measures MBT Increased positive behaviors on objective measures Improved behavior on parent subjective ratings Slightly higher parent satisfaction Individual differences in treatment response About 83% judged as positive treatment responders Treatment responders equally divided between MBT Best SBT Best Both worked well

Waschbusch, Willoughby, Haas et al, under review Interpretations Kids with CU perfectly happy to turn on the positives if in their best interest (increased reward)? But will take advantage if punishment decreases Parent view of MBT advantages may be Related to increased reward for their child Important – 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” response Many 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 punishment Rather, 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 stimuli If 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 consequence Consistency in applying definitions Modified Treatment Inadvertently 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-only Important to assess CU in children with CP CU traits common among children with CP Normally distributed within CP children CPCU and CP-only differ in many important ways Suggests different etiological pathways Children with CU traits seem to show a less positive response to behavior therapy Reported in two independent, recent reviews Less positive response does not mean lack of response BT as necessary but not sufficient treatment Promising treatment approaches Individualized psychosocial treatments Kolko & Pardini (2010) Supplementing BT with other approaches Dadds et al (2012): Emotion recognition supplement to PT Stimulant medication Waschbusch et al (2007) Blader et al (2013) Prevention Hyde, 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 unclear Parent, teachers don’t directly observe guilt Children may be prone to dishonesty / deceit Optimal method unclear Exclusively ratings (but interview work beginning) Inventory of Callous Unemotional (ICU) most used scale Role of bias (halo effects, social desirability, etc.) Lack of normative information Unclear 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 struggle Use child’s need for control to advantage? Appeal to child’s self-interest Contact info: Dan Waschbusch Email: [email protected]