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
from NIMH, SSHRC,
NSHRF, IWK health
center, CIBC miracle
network, Dalhousie
University,
Disclosures:
JACP editing stipend
Past funding from drug
companies but not for any
of this work
Collaborators
Mike Willoughby
Bill Pelham
Sarah Haas
Norm Carrey
Greg Fabiano
Jim Waxmonsky
Lisa Burrows-MacLean
Sara King
Brendan Andrade
Andrew Greiner
Beth Gnagy
Omar Kazmi
Kerry Roach
Many undergrad RAs
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
Family dysfunction
Low verbal IQ
Negative / Ineffective parenting
Deviant social cognition
Adolescent Onset
Rebellious
Reject social norms / hierarchies
Affiliate with deviant peers
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
Probability of Serious Violence
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
0
13
14
15
16
17
18
19
20
Age
Loeber, Farrington, Stouthamer-Loeber & White, 2008
21
22
23
24
25
8
None (56%)
7
Child onset persist (10%)
Average #
6
Child onset desist (8%)
5
Adol onset (26%)
4
3
2
1
0
Variety
Number
Official Convictions at Age 26
Moffitt, Caspi, Harrington, & Milne (2002)
35
None (46%)
% of Group
30
Child onset persist (11%)
25
Child onset desist (24%)
20
Adol onset (20%)
15
10
5
0
Self reported violence
Violence conviction
Violence at Age 32
Odgers, Moffitt et al (2008)
35
None (46%)
% of Group
30
Child onset persist (11%)
25
Child onset desist (24%)
20
Adol onset (20%)
15
10
5
0
Psychiatric Disorder
Odgers et al (2007)
Mental Health Impairment
70
None (46%)
% of Group
60
Child onset persist (11%)
50
Child onset desist (24%)
40
Adol onset (20%)
30
20
10
0
Good / Excellent Health
Odgers et al (2007)
Hospitalized Past Year
Average # in Past Year
6
None (46%)
5
Child onset persist (11%)
4
Child onset desist (24%)
Adol onset (20%)
3
2
1
0
# GP visits
Odgers et al (2007)
Physical health problems
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 20012003
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
Impairment Items
Mom
Teacher
Mom
Teacher
Affect items on CU Scale
Mom
Teacher
‐‐
.28*
‐‐
Mom
.73*
.24*
‐‐
Teacher
.36*
.54*
.41*
Affect Items
Red font = cross-informant correlation of same trait
‐‐
Impair Controlling Affect
Overall Impair
Affect Controlling Impair
Mom
Teacher
Mom
Teacher
Mom
.39*
.10
.11
.29*
Teacher
.30*
.12
.04
.28*
Mom
.20*
.05
.33*
.17*
Teacher
.17*
.21*
.20*
.22*
Mom
.11
.02
.36*
.20*
Teacher
.03
.05
.23*
.31*
Mom
.05
‐.07
.36*
.37*
Teacher
.01
.07
.13
.32*
React Aggress
Proact Aggress
Relate Aggress
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
Mom
.53*
.25*
Teacher
.18*
.53*
Mom
.60*
.24*
Teacher
.21*
.67*
Mom
.67*
.30*
Teacher
.13
.66*
Mom
.55*
.11
Teacher
.15
.59*
Overall Impair
React Aggress
Proact Aggress
Relate Aggress
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
Clinic Sample
Community Sample
100.0
100.0
90.0
78.7
Boys (n = 806)
90.0
Girls (n = 741)
80.0
70.0
70.0
60.0
60.0
% of Sex
% of Sex
80.0
87.3
50.0
40.0
52.5
50.0
40.0
31.2
30.0
30.0
20.0
Boys (n =
141)
20.0
15.9
10.3
10.0
27.0
22.5
4.1 2.0
1.4 0.4
0.0
25.5
15.0
10.0
16.3
10.0
0.0
Not at all Just a little
Pretty
much
Waschbusch et al; 2005
Very much
Not at all Just a little
Pretty
much
Waschbusch et al; 2007
Very much
Sex
25
Boys (n = 144)
Girls (n = 41)
% of Sample
20
15
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
Non-CP
25
Not CP (n=56)
% of Sample
20
15
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
ODD
35
30
ODD (n = 62)
% of Sample
25
20
15
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)
% of Sample
25
20
15
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)
ODD (n = 62)
CD (n = 65)
30
% of Sample
25
20
15
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
100.0
None
CU
0.2
100.0
13.9
90.0
90.0
28.3
46.6
70.0
% of Sample
70.0
% of Sample
2.0
80.0
80.0
60.0
50.0
CU
99.8
86.1
40.0
30.0
53.4
50.0
10.0
10.0
0.0
0.0
CD
71.7
30.0
20.0
ODD
98.0
40.0
20.0
None
75.4
60.0
24.6
None
ODD
Community Sample
Clinic Sample
Waschbusch et al; 2005
Waschbusch et al; 2007
CD
Informant
% of Sample
45
40
Teacher (n = 143)
35
Parent (n = 165)
30
25
20
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)
Number of Publications
120
100
80
60
40
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
# of Cars Played
300
a
b
250
b
200
150
100
50
0
Non-Anxious CU
O’Brien & Frick, 1996
Anxious CU
Controls
350
b
300
a
# of Trials
250
a
a
200
Clinic Control
ADHD-only
ADHD/CP-only
ADHD/CP-CU
150
100
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
30
36
36
Shared
environment
34
Viding et al (2005)
Genetics
Nonshared
environment
0
Shared
environment
81
Nonshared
environment
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
CU-only
CP-only
CP/CU
1.05
1
0.95
0.9
0.85
0.8
Overtly aggressive
Type of Solution
Waschbusch, Walsh et al (2007)
Prosocial
Antisocial Behavior
CPCU and CP-only compared in 118 studies
89% provide evidence of greater antisocial in CPCU
More severe, varied and frequent
More delinquency / recidivism
(Frick et al, 2003, 2005; Pardini et al, 2006, 2008;)
(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
% of Group
Control
60
CU‐only
50
CP‐only
CP/CU
40
30
20
10
0
Any
Frick, Cornell et al (2003)
Violence
Type of Delinquent Act
Status
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
9
8
Aggression
7
6
5
4
3
2
1
0
Control
b
CP-only
CP/CU
a
a
Affect
4
3.5
3
Anger
2.5
2
1.5
1
0.5
0
Control
CP-only
CP/CU
Behavior
10
9
8
Control
CP-only
b
CP/CU
Aggression
7
6
a
5
4
a
3
2
1
0
Low
High
Level of Provocation
Affect
4
3.5
3
Control
CP-only
CP/CU
Anger
2.5
2
1.5
1
0.5
0
Low
High
Level of Provocation
Behavior
10
Control
9
CP-only
8
CP/CU
Aggression
7
6
5
Highly Provoked
By “Opponent”
4
3
2
1
0
1
2
3
4
Final Trials of Task
5
6
Affect
4
Control
Highly Provoked
By “Opponent”
3.5
CP-only
3
CP/CU
Anger
2.5
2
1.5
1
0.5
0
1
2
3
4
Final Trials of Task
5
6
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
Crime measured age 23
Fear conditioning
measures at age 3
0.08
Conditioned Response
0.07
0.06
0.05
0.04
0.03
Controls (n = 274)
0.02
Criminals (n = 137)
0.01
0
CS-
CS+
Goa, Raine, Venables & Dawson (2010)
CS- = 3 tones not
associated with aversive
white noise
CS+ = 9 tones associated
with aversive noise
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
% Negative Affect
0.3
0.25
0.2
Control
CP-only
CPCU
0.15
0.1
0.05
0
Talk
Still Face
Willoughby, Waschbusch, Moore, & Propper (2011)
Reunion
Heart Period (Hi = Low Arousal)
435
430
425
420
415
Control
410
CP‐only
405
CPCU
400
395
390
Talk
Still Face
Willoughby, Waschbusch, Moore, & Propper (2011)
Reunion
Average research assistant rating following 36 month visit
2
1.5
1
0.5
Control
CP-only
CP/CU
0
-0.5
-1
-1.5
Happiness
Irritability
Persistence
Willoughby, Waschbusch, Moore, & Propper (2011)
Gross movement
Mother temperament ratings at 3 and 6 months (averaged)
7
6
Control > CP-only > CP/CU
Control, CU > CP-only
5
4
Control
CP-only
CP/CU
CP-only > control > CP/CU
3
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 CPonly 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
# of ODD/CD Symptoms
8
7
6
5
CP-only
CP/CU
4
3
2
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.
NOTE
THE
LIMITED
RANGE
Teacher Rated Oppositional Defiance
R2 = .22; R2change = .004; p < .05
3
2.5
2
b = ‐0.003 (ns)
1.5
Low CU
b = ‐0.045 (p < .05)
1
High CU
0.5
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
Teacher Rated Oppositional Defiance
R2 = .08; R2change = .006; p < .05
3
2.5
b = 0.02 (ns)
2
1.5
Low CU
1
b = 0.11 (p < .05)
High CU
0.5
0
Low
High
Poor Monitoring and Supervision
CU x Inc Disc signif. after age, gender, CU,
parenting
Teacher Rated Oppositional Defiance
R2 = .08; R2change = .01; p < .05
3
2.5
b = ‐0.04 (p < .05)
2
1.5
Low CU
1
b = 0.07 (p < .05)
High CU
0.5
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
b = .15 (ns)
NOTE
THE
SCALE
RANGE
Mom Rated Oppositional Defiant
13
12
11
10
b = ‐.07 (ns)
9
8
Low CU
7
b = ‐.29 (p < .05)
6
5
Mod CU
High CU
4
3
2
1
0
Low
High
Parental Involvement
CU x Pos Parenting signif. after CU, parenting
R2 = .86; R2change = .005; p < .05
15
14
b = .31 (p=.07)
Mom Rated Oppositional Defiant
13
12
11
10
b = .03 (ns)
9
8
7
Low CU
b = ‐.25 (ns)
6
Mod CU
5
High CU
4
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
Mom Rated Oppositional Defiant
13
b = .03 (ns)
12
11
10
9
b = .30 (p < .05)
8
7
Low CU
6
Mod CU
5
High CU
4
b = .57 (p < .05)
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 CPonly 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
Unstable CU
% of Group
80
70
60
50
40
30
20
10
0
Post-Tx
Hawes & Dadds, 2005; 2007
Follow Up
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, placebocontrolled 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
Average / Day
5
CP/CU
4
3
2
1
0
BT-only
BT-Low
Waschbusch, Carrey, Willoughby et al (2007)
BT-High
Rule Violations
Average / Day
90
80
CP-only
70
CP/CU
60
50
40
30
20
10
0
BT-only
BT-Low
Waschbusch, Carrey, Willoughby et al (2007)
BT-High
Conduct Problems
6
CP-only
Average / Day
5
CP/CU
4
3
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
5
5
4
4
Higher Baseline ODD/CD
CP-only
CP-only
3
3
CP/CU
2
2
1
1
0
0
BT-only
BT-Low
BT-High
CP/CU
BT-only
BT-Low
Frequency of Conduct Problems During Treatment
Waschbusch, Carrey, Willoughby et al (2007)
BT-High
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
Average Per Day
20
CP-only
CP/CU
15
10
5
0
None
Waschbusch, Willoughby et al ( in prep)
Low BT
High BT
Rule Violations
70
Average per Day
60
50
40
CP‐only
30
CP/CU
20
10
0
None
Waschbusch, Willoughby et al ( in prep)
Low BT
High BT
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)
Interruptions
18
16
CP-only
14
CP/CU
12
10
8
6
4
2
0
None
Short (5 Min)
Long (10 Min)
Type of Time Out
Waschbusch, Willoughby, Fabiano, et al ( in prep)
Contingent
Being a Poor Sport
10
CP-only
9
CP/CU
8
7
6
5
4
3
2
1
0
None
Short (5 Min)
Long (10 Min)
Type of Time Out
Waschbusch, Willoughby, Fabiano, et al ( in prep)
Contingent
7
Noncompliance
6
CP-only
5
CP/CU
4
3
2
1
0
None
Short (5 Min)
Long (10 Min)
Type of Time Out
Waschbusch, Willoughby, Fabiano, et al ( in prep)
Contingent
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
Teacheronly
Parentonly
Parent / Teacher
Combined
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)
ADHD
83%
82%
98%
ODD
71%
77%
54%
CD
29%
23%
46%
Symptom Counts
% Meeting Criteria
Waschbusch, Willoughby, Haas et al, under review
Measure
Teacheronly
Parentonly
Parent / Teacher
Combined
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)
APSD 10%
91%
94%
94%
APSD 5%
89%
79%
90%
CU Scale Scores
CU Groups
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 negative behaviors
Earn points for positive and lack of negative behaviors
Lose points for negative behaviors
Do NOT lose points for negative behaviors
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
Morning Module
Waschbusch, Willoughby, Haas et al, in prep
Component
Time Out
DRC
Daily reinforce
Weekly reinforce
Standard
Modified
Starts at 10 minutes
Starts at 10 minutes
Can escalate to 20 minutes
Can be reduced to 5 minutes
Standardized goals
Standardized goals
Reward high performance
Reward high performance
Punish poor performance
Do NOT punish poor performance
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
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*
Minutes physical management
0.08
Fewer Time Outs in SBT than MBT
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%
34%
26%
23%
Standard Best
Modified Best
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: dwaschbusch@hmc.psu.edu