Daniel A. Waschbusch, Ph.D

Daniel A. Waschbusch, Ph.D.

Penn State Hershey Medical CenterDepartment of Psychiatry

Florida International UniversityCenter for Children and FamiliesDepartment of Psychology

Funding to Waschbusch from NIMH, SSHRC, NSHRF, IWK health center, CIBC miracle network, Dalhousie University,

Disclosures: JACP editing stipendPast funding from drug companies but not for any of this work

CollaboratorsMike WilloughbyBill PelhamSarah HaasNorm CarreyGreg FabianoJim WaxmonskyLisa Burrows-MacLeanSara KingBrendan AndradeAndrew GreinerBeth GnagyOmar KazmiKerry RoachMany undergrad RAsCounselors in the STPKids and parents in the studies

Common reasons for mental health services (Frick & Silverthorn, 2001)

Negative impact on families (Frick, Lahey et al 1992) and schools (Gottfredson & Gottfredson, 2001)

Relatively prevalent5% to 10% of kids in pediatric care settings (Costello, 1989)

High financial cost to society$70,000 per child over seven years (Foster, Jones, & CPPRG (2004)

DSM-IV categoriesOppositional Defiant Disorder

Negative, hostile, argumentative behaviorConduct Disorder

Aggression to people and animalsDestruction of propertyDeceitfulness or theftSerious rule violations (e.g., truancy, running away)

Both categories also require Patterns of behaviorSerious impairmentExceed developmental norms

Disruptive Behaviors (from Loeber et al, 1992) Age

Cruel to others, stealing, running away 14

from home, truancy, breaking and entering, 13

assault 12

11

10

Lies, physical fights, bullies others, 9

Cruel to animals, breaks rules 8

7

6

Oppositional, defiant, stubborn, noncompliant, 5

tempter tantrums 4

Hyperactive, Impulsive 3

2

Difficult temperament 1

Developmental progression of population masks individual differences (Loeber & Stouthamer-Loeber, 1998)

Benefits of understanding individual differences includes improvement in:

Understanding of correlates and causal pathwaysMatching intervention to need

Lower costBetter outcomes

Childhood onsetEmerge before age 10 to 12Associated with with numerous dispositional and contextual risk factors

Adolescent onsetEmerge after age 10 to 12Associated with contextual risk factors

Supported by decades of research (Robbins, 1970’s; Moffitt, 1993, 2003; Loeber, 1988)

Childhood Onset Adolescent OnsetFamily dysfunction RebelliousLow verbal IQ Reject social norms / hierarchiesNegative / Ineffective parenting Affiliate with deviant peersDeviant social cognition Low parental monitoring /

supervisionPeer / Social rejectionInattentionPoor impulse control

Moffitt, 1993, 2003; Loeber, 1988; many others

Not all child-onset cases have poor outcomes50% persist, 50% desist (Loeber, 1982; Olweus, 1982)

Not all adolescent-onset cases desistCan get “trapped” in antisocial lifestyle

arrest, school drop out, teenage pregnancy, etc.

Likely many different trajectories (Loeber & Stouthamer-Loeber, 1998)

Childhood onset that persists or desistsAdolescent onset that persists or desistsAdult onset that persists of desists

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

13 14 15 16 17 18 19 20 21 22 23 24 25

Prob

abili

ty o

f Ser

ious

Vio

lenc

e

Age

NoneChild onset persistChild onset desistAdol onset

Loeber, Farrington, Stouthamer-Loeber & White, 2008

0

1

2

3

4

5

6

7

8

Variety Number

Aver

age

#

Official Convictions at Age 26

None (56%)

Child onset persist (10%)

Child onset desist (8%)

Adol onset (26%)

Moffitt, Caspi, Harrington, & Milne (2002)

0

5

10

15

20

25

30

35

Self reported violence Violence conviction

% o

f Gro

up

Violence at Age 32

None (46%)



Adol onset (20%)

Odgers, Moffitt et al (2008)

0

5

10

15

20

25

30

35

Psychiatric Disorder Mental Health Impairment

% o

f Gro

up

None (46%)



Adol onset (20%)

Odgers et al (2007)

0

10

20

30

40

50

60

70

Good / Excellent Health Hospitalized Past Year

% o

f Gro

up

None (46%)



Adol onset (20%)

Odgers et al (2007)

0

1

2

3

4

5

6

# GP visits Physical health problems

Aver

age

# in

Pas

t Yea

r

None (46%)



Adol onset (20%)

Odgers et al (2007)

Different pathways to antisocial behaviorChildhood onset = greatest persistence and severity

But also differences within child-onsetPersistently antisocial vs. desist over development

Suggests need to differentiate within child-onsetCallous-Unemotional traits may be a useful construct for this purpose

Evidence throughout history, even in ancient timesE.g., Nero

Poisoned his stepbrotherMurdered his motherKicked his 2nd wife to death when she was pregnantBurned captured Christians in his garden as a source of light

Hervey Cleckley (1941)Case studies of several individuals who

Were irresponsible but not necessarily violent, aggressive, antisocialSeemed unconcerned about the impact of their behaviors on themselves or others

Based on these, proposed 16 common features One of 1st to conceptualize psychopathy as having underlying pathology despite outward appearance of robust mental healthBecame foundation of all subsequent work

David Lykken (1957)First empirical test of Cleckley’s conceptualizationFirst evidence for several constructs that remain central to understanding psychopathy

Passive avoidance deficit (deficient learning from punishment )Decreased skin response to punishmentDecreased anxiety

Bob Hare (1970s and 1980s)Developed the Pscyhopathy Checklist (PCL) and PCL-R to operationalize Cleckley’s criteriaPropelled an enormous amount of psychopathy researchCurrently most prominent psychopathy researcher

Deficient affective experienceLack of remorse or guiltShallow affectCallous / lack of empathy

Arrogant and deceitful interpersonal styleSuperficial charmConning / manipulativePathological lying

Irresponsible and impulsive lifestyleLack of long term goalsFailure to accept responsibility for own actionsParasitic lifestyle

Cooke & Michie (2001); Hare (2006); Patrick (2010)

More serious and violent crimes (Campbell, Porter & Santor, 2004)

Account for large portion of “cold blooded” murder (Woodworth & Porter, 2002; Porter et al, 2003)

Higher rates of recidivism (Salekin, 2008)

Less responsive to treatment – may get worse rather than better (Harris & Rice, 2006)

Over-focused on rewards and less responsive to punishment (Newman, 1998)

Less physiological arousal (Patrick, 2007)

Reduced empathy / response to fear in others (Patrick, 2001)

125 adults who committed homicide34 psychopaths, 91 non-psychopaths

Compared characteristics of the homicidesMurders perpetrated by psychopaths:

Almost twice as likely to be instrumentalLess likely to have impulsive and anger features

In short, psychopathy more highly associated with “cold blooded” murder

Woodworth & Porter (2002)

Characterized by:Lack of remorse or guilt after doing wrongLack of empathy or concern for others (callous)Unconcerned about own performanceShallow or deficient affect

Modifier of conduct disorder in DSM-Vlimited prosocial emotions

Reduced reactivity to anticipated aversives?

Are CU Traits real?Are they prevalent enough to care about?Should we study CU traits?Do CU traits matter?What do we do to help kids who show them?

Are CU Traits real?Are they prevalent enough to care about?Should we study CU traits?Do CU traits matter?What do we do about them?

Item Alternative Interpretation

Impairment Items

3. Is concerned about how well he/she does in school School impairment

7. Is good at keeping promises ADHD

20. Keeps the same friends Peer impairment

Affect / CU Items

12. Feels bad or guilty when she/he does something wrong Affect / CU

18. Is concerned about the feelings of others Affect / CU

19. Does not show feelings or emotions Affect / CU

“Isn’t CU really just a marker for impairment?” – me, repeatedly, 1999 or so

Antisocial Process Screening Device – CU Scale:

How does APSD perform when you divide the “impairment” vs. CU items?Clinical sample

Halifax Summer Treatment Program intakes 2001-2003Parent and teacher ratings on about 180 children

APSDDisruptive Behavior Disorder - ADHD, ODD, CDImpairment Rating ScaleReact/Proact/Relationship Aggression

Impairment items on CU scale Affect items on CU Scale

Impairment Items Mom Teacher Mom Teacher

Mom ‐‐

Teacher .28* ‐‐

Affect Items

Mom .73* .24* ‐‐

Teacher .36* .54* .41* ‐‐

Red font = cross-informant correlation of same trait

Impair Controlling Affect Affect Controlling Impair

Overall Impair Mom Teacher Mom Teacher

Mom .39* .10 .11 .29*

Teacher .30* .12 .04 .28*

React Aggress

Mom .20* .05 .33* .17*

Teacher .17* .21* .20* .22*

Proact Aggress

Mom .11 .02 .36* .20*

Teacher .03 .05 .23* .31*

Relate Aggress

Mom .05 ‐.07 .36* .37*

Teacher .01 .07 .13 .32*

Community sampleBEST Project: Elementary school intervention implemented in six schoolsParent and teacher ratings on about 1550 children at baseline

MeasuresCU Screening measure

Three items generated by psychopathy experts:Lacks remorseSeems to enjoy being meanIs cold or uncaring

Likert Ratings from 0 (“not at all” ) to 3 (“very much”)

Mom Teacher

Overall Impair

Mom .53* .25*

Teacher .18* .53*

React Aggress

Mom .60* .24*

Teacher .21* .67*

Proact Aggress

Mom .67* .30*

Teacher .13 .66*

Relate Aggress

Mom .55* .11

Teacher .15 .59*

Parent CU with Teacher CU: r = .22*

Slenderman Stabbing, Wisconsin, June 2014Two 12 year olds stabbed another 12 year old 19 times to induce a visit from “slenderman”

NY Times Article, June 8, 2014:

Evidence that CU traits are “real”Statistical evidence that they are not just a marker for impairmentAnecdotal evidence that they present in important ways “in the real world”

Newer CU measures largely avoid the potential “impairment confound” problem

Are CU Traits real?Are they prevalent enough to care about?Should we study CU trait?Do CU traits matter?What do we do about them?

Justice settings20% of adolescent offenders (Lindberg, 2009; Salekin, 2004)

Community settings (Rowe, Maughan et al, 2010)

1% CD/CU1% CD-only3% CU-only

Clinical settingsMost clinicians believe they have treated children with high CU traits (Salekin et al, 2001)

30% to 50% of children with CP (Frick et al, 2014)

Evidence that CU is normally distributed within CP

Community Sample

78.7

15.9

4.1 1.4

87.3

10.3

2.0 0.40.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Not at all Just a little Prettymuch

Very much

% o

f Sex

Boys (n = 806)

Girls (n = 741)

Clinic Sample

31.227.0 25.5

16.3

52.5

22.515.0

10.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Not at all Just a little Prettymuch

Very much

% o

f Sex

Boys (n =141)

Waschbusch et al; 2005 Waschbusch et al; 2007

Sex

0

5

10

15

20

25

30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85

% o

f Sam

ple

T-Score from the APSD CU Scale

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

Waschbusch et al; 2007 – STP 2001 - 2003

Non-CP

0

5

10

15

20

25

30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85

% o

f Sam

ple


Not CP (n=56)


ODD

0

5

10

15

20

25

30

35

30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85

% o

f Sam

ple


ODD (n = 62)


CD

0

5

10

15

20

25

30

35

30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85

% o

f Sam

ple


CD (n = 65)


Diagnosis

0

5

10

15

20

25

30

35

30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85

% o

f Sam

ple


Not CP (n=56)ODD (n = 62)CD (n = 65)


Community Sample

99.886.1

53.4

0.2

13.9

46.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

None ODD CD

% o

f Sa

mpl

e

None CU

Clinic Sample

98.0

71.7

24.6

2.0

28.3

75.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

None ODD CD

% o

f Sa

mpl

e

None CU

Waschbusch et al; 2005 Waschbusch et al; 2007

Informant

0

5

10

15

20

25

30

35

40

45

0 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 70 to 72

% o

f Sam

ple

Total Score from the ICU

Teacher (n = 143)

Parent (n = 165)

Waschbusch & Pelham – STP 2011-2012

CU Traits are not uncommon4% of normal population

1 kid in every classroomNormally distributed among clinical samples

Are CU Traits real?Are they prevalent enough to care about?Should we study CU?Do CU traits matter?What do we do about them?

Antisocial Process Screening Device (APSD) (Frick & Hare, 2001)

Likert Ratings – parent, teacher, self report versionsPros

Six items – easy and fastFactor structure, validity, test-retest reliability well supportedPublished normsWidely used – default measure of CU in kids

ConsLow alphas in some studiesOnly six items --

Other measures – promising, but not establishedInventory of Callous-Unemotional Traits (Frick)Child Psychopathy Scale – Revised (Lynam)Dadds revision of the APSD (Mark Dadds)

Most of these – including APSD – use positively worded items that are reverse scored.

Is failure to endorse “feels bad when he/she does wrong” the same as endorsing “does not feel bad when he/she does wrong”?

RisksHighly negative connotation; stigmatizing

Comes out of psychopathy research

Often viewed as a stable, untreatable condition

The risks can be mitigatedEducation about developmental and individual differencesCareful application of the construct in clinical, educational, judicial contexts

Don’t get carried away

-The Onion (Dec 7, 2009)

Children display hallmarks of psychopathy:Poor impulse/anger controlLittle regard for how own behavior affects othersWill exploit others to get what they wantQuickly become boredNeed constant attention and validationEgocentric

BenefitsMay improve understanding of the most seriously impaired children which in turn…May lead to better treatments, which in turn…May lead to better outcomes

Opportunity cost: there are risks of not pursuing this line of work

Miss chance to deflect trajectory of those at highest risk for the most seriously antisocial behaviors

“Conscience does make cowards of us all”--William Shakespeare in Hamlet

Self-reported key traits for success as a venture capitalist:

DeterminationCuriosityInsensitivity

CU does not condemn one to a life of crime and can be associated with success

“I always said he would grow up to be either a Nobel prize winner or a serial killer”

– mom of 9 year old boy with high CU

“The road to the top is hard. But it’s easier to climb if you lever yourself up on others. Easier still if they think something’s in it for them”

– Anonymous CEO

Kevin Dulton (2012) – The Wisdom of PsychopathsJennifer Kahn (2012) – NY Times Magazine

“It’s not just enough to fly in first class; I have to know my friends are flying in coach”

– Jeremy Frommer, CEO, Carlin Financial

The great thing about insensitivity is “…it lets you sleep at night”

– Jon Moulton, venture capitalist, Financial Times interview

Kevin Dulton (2012) – The Wisdom of PsychopathsMichael Lewis (March 31, 2014) - New York Times Magazine

“I have no compassion for those whom I operate on. That is a luxury I simply cannot afford. When I am in the theater I am reborn as a cold, heartless machine, totally at one with scalpel, drill, and saw. When you’re cutting loose and cheating death high above the snowline of the brain, feelings aren’t fit for purpose. Emotion is entropy – and seriously bad for business. I’ve hunted it down to extinction over the years”

--Anonymous Neurosurgeon

Kevin Dulton (2012) – The Wisdom of Psychopaths

CU Traits in kids:Are realHave high potential to stigmatizeAlso high potential to identify kids who need helpDo not condemn kids to a life of crime


5% of children in community sample30% to 50% in clinic referred CP sample

May be normally distributed in clinic samplesNon-overlapping with ODD/CD

25% to 50% of ODD/CD in community sample50% to 75% of ODD/CD in clinical sample

More prevalent in boys than girlsOther research suggests there may be different etiological underpinnings as well (Dadds et al 2009; Fontaine et al, 2010)

0

20

40

60

80

100

120

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Num

ber

of P

ublic

atio

ns

Publication Year

Salekin & Lynam (2010) – estimated from fig 1.1

Frick et al (2014) – review in Psyc Bull269 studies of CU traits since 1990

Of these, 191 (71%) published in 2007 or later

Focused on studies that compared CPCU vs. CP-only

Differences in many areas including...

Frick et al (2014)

Moral DevelopmentLess empathy for victims (Pardini et al, 2003; Hastings et al, 2000)

Less able to distinguish moral violations from conventional violations (Blair, 1997, 2001; Fisher & Blair, 1998)

Frick et al (2014)

Emotional ProcessingLess accurate at identifying fear, sadness (Blair et al, 2000, 2001, 2005, Dadds et al, 2006; Woodworth & Waschbusch, 2008)

Less physiological, behavioral response to distress and to negative emotional cues (Frick et al, 2003; Kimonis et al, 2006; Loney et al 2003; Marsh et al, in press; Sharp et al, 2006)

Frick et al (2014)

Cognitive abilitiesLess likely to change behavior in response to punishment (Barry et al, 2000; Budhani & Blair, 2005; O’Brien et al, 1996)

Higher verbal IQ (no diffs vs. controls) (Christian et al, 1997; Loney et al, 1998)

Frick et al (2014)

Computer tasks argue that CU kids react differently to reward and punish

Card playing task and its variants most commonPlay 100 cardsFirst 10 cards: all reward no point lossNext 10 cards: 9 reward, 1 point lossNext 10 cards: 8 reward, 2 point lossEtc.DV = how many cards will kids play until they stop?

0

50

100

150

200

250

300

350

Non-Anxious CU Anxious CU Controls

# of

Car

s Pla

yed b

b

O’Brien & Frick, 1996

a

0

50

100

150

200

250

300

350

Group

# of

Tri

als

Clinic ControlADHD-onlyADHD/CP-onlyADHD/CP-CU

a aa

b

Barry et al, 2000

BiologyLess amygdala activation when processing fear (Jones et al, 2009; Marsh et al, 2009)

Abnormal ventromedial prefrontal cortex activation during a punishment reversal task (Finger et al, 2008)

Lower HR at baseline and in emotional situations (Raineet al, 2005; Amastassiou-Hadjicharalmbous & Warden, 2008)

Lower salivary cortisol but no differences on testosterone (Loney et al, 2006)

Frick et al (2014)

Co-Occurring problemsLower likelihood of anxiety (Frick, Lilienfeld et al, 1999)

Less likely to commit suicide (Javdani, Sadeh, & Edelyn, 2011)

Specific and unique associations with proactive aggression (Frick & Ellis, 1999; Waschbusch & Willoughby, 2007)

Role of ADHD unclear

Frick et al (2014)

Genetic / Family StudiesGenetics account for 42% to 68% of CU2-3 times greater heritability of antisocial behavior in CP/CU (Viding et al, 2005)

Antisocial Personality and Arrest 3-6 times higher in CP/CU parents than in CP-only parents (Frick et al, 1994; Christian et al, 1997)

Frick et al (2014)

30

34

36

CP-only

Genetics

Sharedenvironment

Nonsharedenvironment

810

36

CP/CU

Genetics

Sharedenvironment

Nonsharedenvironment

Viding et al (2005)

Social CognitionAccurately interpret peer intent (unlike CP-only) (Frick et al, 2003; Waschbusch, et al, 2009)

More aggressive responses before and after provocation from a peer (Munoz et al, 2008; Waschbusch et al, 2009)

No difference in types of solutions generated in response to social problems (Waschbusch et al, 2007)

More positive evaluations of aggressive solutions (Pardini et al, 2003)

Believe aggression will have more positive, fewer negative consequences

Believe aggression will succeed

0.80.850.9

0.951

1.051.1

1.151.2

1.251.3

Overtly aggressive ProsocialType of Solution

ControlCU-onlyCP-onlyCP/CU

Waschbusch, Walsh et al (2007)

Antisocial BehaviorCPCU and CP-only compared in 118 studies 89% provide evidence of greater antisocial in CPCU

More severe, varied and frequent (Frick et al, 2003, 2005; Pardini et al, 2006, 2008;)

More delinquency / recidivism (Christian et al 1997; Falkenbach et al. 2003)

CU independently predicts antisocial behavior in adolescence and early adulthood (Loeber et al, 2002, 2008; Lynam, 1997; McMahon et al, 2010)

Frick et al (2014)

0

10

20

30

40

50

60

70

Any Violence Status

% of G

roup

Type of Delinquent Act

ControlCU‐onlyCP‐onlyCP/CU

Frick, Cornell et al (2003)

60 Participants32 Controls14 with CP-only14 with CP/CU

Competed in reaction time taskWins and losses fixed ahead of timeStandardized provocations (low or high) from a “peer”No real peer – actually a computer

Two aggression conditionsInstrumental

0 to 10 points“It will make it harder for him/her to win the game”

Hostile: 0 to 10 seconds of white noice0 to 10 seconds of white noise burst“It won’t make it harder for him/her to win the game, but it really bugs other kids”

Helseth, Waschbusch et al, in press, JACP

When they lost, “opponent” would provoke themLow provocation:

Took 0 to 2 points / white noise burst“You lost, but you’re getting better”

High provocation:Took 8 to 10 points / white noise burst“Nice try speedo! What’s the matter is your hand stuck in cement?”

When they won, “opponent” would provoke themSent a consequence to “opponent”

Instrumental aggression: 0 to 10 pointsHostile aggression: 0 to 10 seconds of white noise burst

Sent a message to opponentOnly presenting instrumental condition

Most consistent with past researchResults similar across conditionsBoth conditions get complex and messy in presentation format

Helseth, Waschbusch et al, under review

Behavior

0

1

2

3

4

5

6

7

8

9

10

Agg

ress

ion

ControlCP-onlyCP/CU

a

b

a

Affect

0

0.5

1

1.5

2

2.5

3

3.5

4

Ang

er

ControlCP-onlyCP/CU

Behavior

0

1

2

3

4

5

6

7

8

9

10

Low High

Agg

ress

ion

Level of Provocation

ControlCP-onlyCP/CU

a

a

b

Affect

0

0.5

1

1.5

2

2.5

3

3.5

4

Low High

Ang

er

Level of Provocation

ControlCP-onlyCP/CU

Behavior

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6

Agg

ress

ion

Final Trials of Task

ControlCP-onlyCP/CU

Highly Provoked By “Opponent”

Affect

0

0.5

1

1.5

2

2.5

3

3.5

4

1 2 3 4 5 6

Ang

er

Final Trials of Task

ControlCP-onlyCP/CU

Highly Provoked By “Opponent”

Under-regulated pathway – ADHD/CP-onlyDifficult temperament

impulsive, quick to anger, reactive

Interacts with ineffective parentingharsh, inconsistent discipline, poor monitoring and supervision, low positives, etc.

Under-arousal pathway – ADHD/CP-CULow physiological arousal in response to:

Punishment / parent socializationOther’s distress

EvidencePhysiological under-arousal when anticipating aversive stimuli at 3 years significantly associated with:

Aggression at 8 years (Gao, Raine et al, 2010a)

Crime at 23 years (Gao, Raine, et al, 2010b)

Behavioral under-arousal during still face procedure at 3 months associated with CU ratings at 36 months (Willoughby, Waschbusch, Moore, & Propper, 2011) Evidence

Implies different biological and parenting underpinnings for CPCU and CP-only children

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

CS- CS+

Con

ditio

ned

Res

pons

e

Controls (n = 274)

Criminals (n = 137)

Crime measured age 23Fear conditioning measures at age 3

CS- = 3 tones not associated with aversive white noiseCS+ = 9 tones associated with aversive noise

Goa, Raine, Venables & Dawson (2010)

Secondary analysis of Durham Child Health and Development Study

178 healthy infants recruited at 3 monthsFollowed through 36 months

Selected subsample based on 36 month behavior ratings completed by parents

CP-only (n = 12)CPCU (n = 7)Controls (n = 10) – demographically matched

Willoughby, Waschbusch, Moore, & Propper (2011)

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Talk Still Face Reunion

% N

egat

ive A

ffec

t

ControlCP-onlyCPCU


390

395

400

405

410

415

420

425

430

435

Talk Still Face Reunion

Heart Period (Hi = Low

Arousal)

ControlCP‐onlyCPCU


-1.5

-1

-0.5

0

0.5

1

1.5

2

Happiness Irritability Persistence Gross movement

ControlCP-onlyCP/CU

Average research assistant rating following 36 month visit


1

2

3

4

5

6

7

Regulation Fear Soothability

ControlCP-onlyCP/CU

CP-only > control > CP/CU

Control > CP-only > CP/CU

Mother temperament ratings at 3 and 6 months (averaged)

Control, CU > CP-only


Parenting predicts later CU in child (Waller et al, 2013)

Negative parenting increases CUPositive parenting decreases CU

Child CU predicts later negative parenting (Hawes et al, 2011;

Salihovic et al, 2012)

Parenting Interacts with Child Temperament (Kochanska, 2007)

Fearless children benefit more from positive parenting, which induces effortful controlFearful children benefit more from gentle but assertive discipline

Child antisocial behavior and ineffective parenting may be more highly associated with CP-only versus CP/CU (Cornell & Frick, 2007; Edens et al, 2008; Hipwell et al, 2007; Oxford et al, 2003; Wooten et al, 1997)

Corporal punishment in childhood associated with psychopathy in adulthood only for children with CP-only at baseline (Lynam et al, 2008)

In other words, CP/CU children had stable CU over development, whereas CP-only developed CU as adults only when they experienced corporal punishment

Parenting factors traditionally associated with antisocial behavior not as important for CU kids

0

1

2

3

4

5

6

7

8

9

Good parenting Poor parenting

# of

OD

D/C

D S

ympt

oms

CP-onlyCP/CU

Andershed et al, 2002; Frost, 2006; Hipwell et al, 2007; Oxford et al, 2003; Wooten et al, 1997;

ParticipantsParents and teachers of 796 students ages 5 to 12In BEST school intervention project (Waschbusch et al, 2005)

MeasuresTeacher rated conduct problems = IOWA OD ScaleMom rated CU = Three-item screenerMom rated Parenting = Alabama Parenting Questionnaire

Minus 4 items dropped at school board request

AnalysesPreliminary analyses (Unconditional Mixed Model) showed no effect of classroom/teacher on ratings)Regressions predicting CP from CU, Parenting, CU x Parenting (plus age and sex as covariates)

CU x Involve signif. after age, sex, CU, Pos Inv.R2 = .22; R2change = .004; p < .05

0

0.5

1

1.5

2

2.5

3

Low High

Teache

r Rated

Opp

osition

al Defiance

Parental Involvement

Low CU

High CU

b= ‐0.003 (ns)

b = ‐0.045 (p < .05)

NOTETHE LIMITEDRANGE

Main Effects step significantR2 = .07; R2change = .04; p < .05CU significant: higher CU = higher teacher ODPos Parenting significant but direction of effects is backward

More pos parenting = more teacher ODValidity of self-report of parenting?

CU x Pos Mon signif. after age, sex, CU, parentingR2 = .08; R2change = .006; p < .05

0

0.5

1

1.5

2

2.5

3

Low High

Teache

r Rated

Opp

osition

al Defiance

Poor Monitoring and Supervision

Low CU

High CU

b= 0.02 (ns)

b= 0.11 (p < .05)

CU x Inc Disc signif. after age, gender, CU, parenting

R2 = .08; R2change = .01; p < .05

0

0.5

1

1.5

2

2.5

3

Low High

Teache

r Rated

Opp

osition

al Defiance

Inconsistent Discipline

Low CU

High CU

b= ‐0.04 (p < .05)

b = 0.07 (p < .05)

ParticipantsParents and teachers of 141 students ages 7 to 13Evaluated as part of intake for STP in HalifaxMostly DBD kids, but also some controls

MeasuresMom and Teacher Rated Conduct problems = IOWA OD ScaleMom rated CU = APSDMom rated Parenting = Alabama Parenting Questionnaire

Minus 4 items dropped by accident

AnalysesSame regressions as before except

Age, Sex not used -- non-significant in all preliminary analysesMom OD and Teacher OD used in separate regressions

Interaction step never significantMain Effects Step of Model

All significant: .14 < R2 < .16; p’s < .05CU significant for every model

higher CU = higher teacher OD

Parenting ScalesHigher Poor Monitor & Supervision = More Teacher ODNo other scales significant (Involvement, Pos Parent, Inconsistent Discipline)

CU x Involve signif. after CU, parentingR2 = .87; R2change = .01; p < .05

NOTETHESCALERANGE

0123456789

101112131415

Low High

Mom

Rated

Opp

osition

al Defiant

Parental Involvement

Low CU

Mod CU

High CU

b = ‐.07 (ns)

b = ‐.29 (p < .05)

b = .15 (ns)

CU x Pos Parenting signif. after CU, parentingR2 = .86; R2change = .005; p < .05

0123456789

101112131415

Low High

Mom

Rated

Opp

osition

al Defiant

Positive Parenting

Low CU

Mod CU

High CU

b = .03 (ns)

b = ‐.25 (ns)

b = .31 (p=.07)

Main Effects step significantR2 = .867; R2change = .86; p < .05CU significant: higher CU = higher mom ODMonitoring & Supervision NOT related to Mom OD

Validity of self-report of parenting?

CU x Pos Parenting signif. after CU, parentingR2 = .88; R2change = .01; p < .05

0123456789

101112131415

Low High

Mom

Rated

Opp

osition

al Defiant

Inconsistent Discipline

Low CU

Mod CU

High CU

b = .30 (p < .05)

b = .57 (p < .05)

b = .03 (ns)

Evidence from two samples (clinical and community) that Neg/Ineff parenting & antisocial behavior

Associated as expected for children with CP-onlyNot associated for children with CP/CU; antisocial high regardless of parenting

Consistent with previously published research (Cornell & Frick, 2007; Edens et al, 2008; Hipwell et al, 2007; Oxford et al, 2003; Wooten et al, 1997)

LimitationsSelf-report of parentingResults vary as a function of CP informantDoes not account for parent characteristics (e.g., higher rate of antisocial personality in CP/CU group)

Traditional parenting practices may be less associated with antisocial behavior in CPCU

Fearless temperament = high risk across parenting stylesEvidence mixed

Parenting and CU mutually influentialChild effects: CU induces worse parentingParent effects: Worse parenting induces CU


Parenting always measured using self reportSelf report has several limitations: (Morsbach & Prinz, 2006)

Accuracy of recall may be poorItems may be unclear or mis-interpretedSocial desirability”Risk of disclosure

No research takes parent’s own characteristics into account

High rates of antisocial in CU kids = less honest or less accurate in self-evaluations?

No experimental evaluations of whether parenting changes linked with CP changes as a function of CUR21 -- address these weaknesses and link PT response to reward sensitivity

Scored but not funded; resubmit in March 2011

Adult psychopathy recalcitrant to treatment (Harris & Rice, 2006; Wong & Hare, 2005)

May get worse in response to some types of treatment (Barbaree, 2005; Rice, Harris, & Cormier, 1992)

Show differential response to contingencies (Dadds & Salmon, 2003; Frick et al, 2001)

Lower physiological arousal in response to distress (Anastassiou-Hadicharalambous & Warden, 2008)In controlled experiments, less likely to learn from punishment, when primed to attend to rewards (O’Brien & Frick; Budhanni et al, 2005)

Speculations that medication may reduce impulsive aggression but increase non-impulsive aggression (Hinshaw & Lee, 2002; Vitiello & Stoff, 1997)

If correct, then standard treatments for conduct problems may be least effective for those most prone to serious, frequent, and violent antisocial behaviors

“Ultimately, the effectiveness of prevention and treatment methods for child and adolescent psychopathy is an empirical question that needs to be investigated”

Farrington, 2005, in a commentary on youth psychopathy

Parent training (PT) is a key intervention for treatment of conduct problems in children

Major component of virtually all empirically supported treatments for CP in kids (Eyberg et al 2008)

Among the most widely used treatment for CP in kids

All have similar procedures and goalsUse principles of behavior therapyIncrease parental attention to positive child behaviorDecrease parental attention to negative behavior

Eleven samples comprising 2,345 youth ages 2 t o 18 yearssmall sample sizes (often < 75)usually clinic referred

9 out of 11 studies (82%) report that pre-treatment CU predicts higher post-treatment CP

Even after controlling for pre-treatment CPNot specific to CD – also apparent in ODDNot specific to informantRobust with respect to parent/family factors

Hawes, Price & Dadds (2014)

24 published studiesMost with adolescents20 of the 24 compared treatment outcomes in CP-only and CPCU18 of the 20 (90%) report worse treatment outcomes for youth with CPCU

Frick et al (2014)

Add treatments to BTStimulant treatmentCognitive / Emotional treatments

Emotional recognition and processing deficitsMoral reasoning deficits

Modify BT to be more effectiveMatch unique learning stylesIndividualizeIntensify

56 Boys ages 4 to 8Met criteria for ODD or CDTreatment = 9 weekly sessions of behavioral PTDependent measures

Home observationsParent ratingsClinical diagnoses

Assessed post-treatment and 6 months later

Hawes & Dadds, 2005; 2007

Post-treatmentCU predicted ODD diagnosis after controlling for ODD and other factorsNot due to treatment implementation (measured using obs and parent report)CU negatively related to TO effectiveness, but not to reward strategies

Parents reported CU kids neither angry nor sad in TO


0102030405060708090

100

Post-Tx Follow Up

% o

f Gro

up

Negative Affect During Time OutStable Low CU

Unstable CU


Boys & girls ages 7-12 yrs with ADHD/CP19 with ADHD/CP-only18 with ADHD/CP-CU

MedicationMethylphenidate (Ritalin®)Evaluated using a within-subjects, randomized, placebo-controlled designDoses

None (placebo) Low Dose (.3 mg/kg) High dose (.6 mg/kg)

Waschbusch, Carrey, Willoughby et al (2007)

Treatment conditionsBmod-onlyBmod + Low DoseBmod + High Dose

Treatment measuresCounselor recorded frequencies of behaviorsAcademic classroom performanceTeacher and counselor IOWA ratings

Inattentive/overactive/impulsive (IO)Oppositional-defiance (OD)


0

1

2

3

4

5

6

BT-only BT-Low BT-High

Aver

age

/ Day

Noncompliance

CP-onlyCP/CU


0

10

20

30

40

50

60

70

80

90


Aver

age

/ Day

Rule Violations

CP-onlyCP/CU


0

1

2

3

4

5

6


Aver

age

/ Day

Conduct Problems

CP-onlyCP/CU


Same pattern emerged for rule violations and noncompliance

Are results simply a function of severity of CP?

0

1

2

3

4

5

6


Lower Baseline ODD/CD

CP-onlyCP/CU

0

1

2

3

4

5

6


Higher Baseline ODD/CD

CP-onlyCP/CU

Frequency of Conduct Problems During Treatment


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)


54 Boys & girls ages 7-12 yrs with ADHD/CPSTP participants

38% never medicated62% in a medication assessmentExcluded those always medicated

Outcome MeasuresCounselor improvement ratingsTime out dataEnd of STP sociometrics

Correlations and RegressionsHaas, Waschbusch, Pelham, King, Andrade, & Carrey (2011)

CU at baseline correlated withImprovement ratings of

Social skills (r = -.46)Sports behavior (r = -.33)Problem solving (r = -.55)Overall (r = -.28)

Time outNumber of time outs/day (r = .36)Minutes per time out (r = .29)Negative behaviors during time out (r = .47)

SociometricsPeer like ratings (r = -.28)

Haas, Waschbusch, Pelham, King, Andrade, & Carrey (2011)

CP and CU correlated (r = .64)After controlling for CP, CU associated with

Improvement ratings of Social skills (Beta = -.47)Problem solving (Beta = -.39)

Time outNegative behaviors in time out (Beta = .40)

For several measures, overall regression was significant but neither CP nor CU beta was


When examined alone, CU significantly associated with outcomes in expected ways

Higher CU indicates less positive treatment responseWhen controlling for CP, pattern is attenuated by not entirely accounted forNoteworthy that CU measured using baseline parent ratings, outcomes were not

Not a method effectTruly predictive – CU measured temporally before treatment


Other (unpublished) studiesSRP re-analysis: Bmod x Med (fully crossed)Fabiano study re-analysis: Time out proceduresMRPS 2011MRPS 2012

Secondary analysis of data from a larger study (Pelham et al, in prep)

Boys & Girls Ages 6 to 12 with ADHD/CP21 children with ADHD/CP-only7 Children with ADHD/CP-CU

Treatments Fully crossedBmod: none vs. low vs. highMed: none vs. low vs. med vs. high

Treatment response measured using point system frequency counts

Waschbusch, Willoughby et al ( in prep)

Analyzed using Mixed ModelsResults

BT and MED main effects always significantBehavior therapy and medication work

Group significant for nearly every measureADHD/CP-CU always worse than ADHD/CP-only

Significant BT x Group interactions forConduct problemsNoncomplianceRule violationsComplaining

Med x Group was never significantMedication works equally well for the groups



0

5

10

15

20

25

None Low BT High BT

Aver

age

Per

Day

Conduct Problems

CP-onlyCP/CU


0

10

20

30

40

50

60

70

None Low BT High BT

Average pe

r Day

Rule Violations

CP‐onlyCP/CU

CP/CU more negative in no treatmentCP-only and CP/CU differences were largely due to change from low to high bmod

CP-only improve between low and high BTCP/CU do not (and may get worse)

What might account for this pattern?One difference between low and high bmod was addition of a weekly punisher (chores) for negative behaviorConsistent with lab task data showing punishment less effective or detrimental for CU


If CP/CU do differ in response to bmod, perhaps it is because of response to punishment such as Time Out (Dadds& Salmon, 2003; Frick and Morris, 2007)

Secondary analysis of data from study of different types of Time Out (Fabiano et al, 2004)

Boys & Girls Ages 6 to 12 with ADHD/CP23 children with ADHD/CP-only10 Children with ADHD/CP-CU

Four Time Out conditionsNo time out (response cost only)Short time out (5 minutes)Long time out (15 min)Contingent time out

Waschbusch, Willoughby, Fabiano, et al ( in prep)

Original study Results

Time out more effective than no time outNo differences across type of time out

Used only a single outcome measure – broad measure of antisocial behaviorDid not distinguish based CU

Re-analysis hypothesesCU would be more negative in all time out conditions

More antisocial and punishment averseDifferences would be largest in fixed rather than contingent

Having some reward for behavior would be especially advantageous for the CU group


0

2

4

6

8

10

12

14

16

18

None Short (5 Min) Long (10 Min) ContingentType of Time Out

InterruptionsCP-onlyCP/CU


0123456789

10


Being a Poor SportCP-only

CP/CU


0

1

2

3

4

5

6

7


Noncompliance

CP-only

CP/CU


CP/CU more negative than CP-only in nearly every condition, regardless of time-outShort TO

Best for CP-only worst for CP/CU (sometimes detrimental)CP/CU greater need for “cool down” time?

Contingent TO best for CP/CU worst for CP-onlyCP/CU more response to incentive?More responsive to being given some control?


CPCU more severe than kids with CP-onlyStimulant medication improved behavior

ADHD or CP rather than CU?Evidence of diminished response to BT?

Selective to BT?Kolko & Pardini, 2012 (eclectic treatment)Hyde et al, 2013 (family intervention)

If BT is less effective, why?

Insensitivity to punishment hypothesized as key component of CU development

Dadds & Salmon, 2003Passive avoidance learning deficit demonstrated in several lab task studies of youth:

Lynam, 1998Frick and colleagues (1996, 2000, 2003)Blair and colleagues (1998, 2001, 2005)

Also over-focus on reward?Reward / punish rarely separated empirically or clinically

“Current treatments may not meet the needs of children with callous-unemotional traits. Specifically, punishment-based approaches may not work optimally. Translational research is needed to develop and evaluate treatments incorporating strict boundaries, consistent rewards, and appeal to self-interest”Moffitt et al, 2008, in a review of high priority research needs for conduct disorder

Purpose: Modify typical BT to meet unique learning style of CPCU kids

Increase reward for non-negative behaviorDecrease punishment (as much as possible) for negative behavior

Funded by R34 grant from NIMHTwo phases

2011: Pilot project with 12 children to develop and try out new behavioral treatment for CU2012: Larger study with 48 children to test feasibility

Within-subjects reversal designA – B – A – C – A – BC – ABaseline – de-emphasize punish – baseline –emphasize reward – baseline – emphasize reward & de-emphasize punish - baseline

N = 11, ages 7 to 11Enrolled in single group that stayed together all summerPrimary purpose was try out procedures

Miller, Haas, Waschbusch et al, 2014

Emphasize rewardSupplemented point system with ticket systemTickets earned throughout week, traded in for toys at end of weekEarned tickets for not demonstrating negative behaviorsExtra rewards in classroom settings

TreatsGame time


De-emphasize punishment2 minute time out vs. 10 minute time outNegative behaviors labeled, but did not result in a point lossDRCs targeted positive behaviors as much as possibleEnd of week reinforcer activity did not have a punishment level

Field trip for high achieversOrdinary day for all others (vs. chores normally for poor achievers0


Conduct ProblemsLow punish bestHi reward worst


Conduct Problems

Miller, Haas, Waschbusch et al (2014)

Huge variability in treatment responseAcross measures & kidsNo different than any other treatment study

There is no substitute for pilot workKids quickly found weak points of treatment and used them to their advantageLack of predictability may be beneficial

N = 48Age: M = 9.3 (range: 7 to 12.6)Sex: 38 boys, 10 girlsIQ: M = 102 (range: 81 to 128)Race: 69% white; 13% African-American; 18% otherEthnicity: 52% Hispanic / LatinoSES: Poverty to Affluent

All with high CU (t-score > 65 on APSD)

Waschbusch, Willoughby, Haas et al, under review

Measure Teacher-only

Parent-only

Parent / Teacher Combined

Symptom CountsADHD-hyper/impulse 6.1 (2.8) 6.6 (2.1) 8.0 (1.4)ADHD-inattention 6.5 (2.8) 6.9 (2.7) 8.3 (1.6)ODD 4.6 (2.8) 4.7 (2.1) 6.5 (1.5)CD 1.6 (1.8) 1.5 (1.9) 2.6 (2.2)

% Meeting CriteriaADHD 83% 82% 98%ODD 71% 77% 54%CD 29% 23% 46%


Measure Teacher-only

Parent-only

Parent / Teacher Combined

CU Scale ScoresICU total scale sum 40 (11) 34 (11) 48 (9)APSD t-score 73 (11) 78 (10) 73 (6)Dadds sum 11 (4) 7 (3) 12 (3)CPS CU Scale 3 (2) 2 (1) 4 (1)

CU GroupsAPSD 10% 91% 94% 94%APSD 5% 89% 79% 90%


Conducted in the STP4 groups of 12 kids

Within-subjects treatment manipulation4 weeks of standard STP4 weeks of modified STPOrder counter-balanced across groups

Two treatmentsStandard STP – balanced reward and punishModified STP – increase reward, decrease punish


Component Standard ModifiedPoint System Earn points for positive and lack of

negative behaviorsEarn points for positive and lack of

negative behaviors

Lose points for negative behaviors Do NOT lose points for negative behaviors

Morning Module Awards for HPK, Most Improved Awards for HPK, Most Improved

Award for Best Social Skill Award for Best Helper

Social Skill Review Emotion Skill Review

Daily Check In None Counselor‐initiated brief positive encounter with each child

Sit‐Out Cards None Three “I need a 5 minute break” cards per day

Waschbusch, Willoughby, Haas et al, in prep

Component Standard ModifiedTime Out Starts at 10 minutes Starts at 10 minutes

Can escalate to 20 minutes Can be reduced to 5 minutes

DRC Standardized goals Standardized goals

Reward high performance Reward high performance

Punish poor performance Do NOT punish poor performance

Daily reinforce Reward high performance Reward high performance


Standard sport (BB, Softball, Soccer) at end of each day

Chance to earn a fun game at end of each day

Weekly reinforce Reward high performance Reward high performance



Mixed ModelsTreatment as predictorWeek, Sex, Medication as covariates

Outcomes: Composite STP categoriesParent, counselor ratings

Transformed data to reduce skewResults robust with respect to extreme cases


Max weekly average during treatment:44.5 Time Outs per day22 Minutes per day in physical management103 Conduct Problems per day

About 1 SD higher than BT-only group in Pelham et al (2000) – MTA sample


Point System Category Effect Size NotesConduct problems 0.29* Less conduct problems in SBT than MBTNegative verbalizations 0.15+ Less negative verbals in SBT than MBTComplaining 0.11Interruption 0.10Noncompliance 0.11Rule violations 0.23* Less rule violations in SBT than MBTPositive peer behaviors 0.53* More positive with peers in MBT than SBTMinutes in Time Out -0.03Number of Time Out 0.25* Fewer Time Outs in SBT than MBTMinutes physical management 0.08


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

Parent Rating Scale Effect Size NotesInattentive-Overactive 0.13Oppositional-Defiant -0.45* Less oppositional in MBT than SBTSerious conduct problems -0.24* Less conduct problems in MBT than SBTRule following problems -0.37* Less rule following problems in MBT than SBTOverall problems -0.11


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

26%

23%34%

17%

Which Treatment Worked Best for This Child?

Standard BestModified BestBoth EffectiveNeither Effective

Conduct Problems Negative Verbalization

SBT reduced negative behaviors on objective measures

MBT Increased positive behaviors on objective measuresImproved behavior on parent subjective ratingsSlightly higher parent satisfaction

Individual differences in treatment responseAbout 83% judged as positive treatment respondersTreatment responders equally divided between

MBT BestSBT BestBoth worked well


InterpretationsKids with CU perfectly happy to turn on the positives if in their best interest (increased reward)?But will take advantage if punishment decreasesParent view of MBT advantages may be

Related to increased reward for their childImportant – start of virtuous cycle?


Hypothesis 1: Perhaps there’s a treatment response that we did not detect (yet)

No controls = do not really know “true” responseMany other measures yet to examine, some that look promising

Hypothesis 2: Behavior – Consequence consistency or salience as unintended confound

Not entirely accurate that children with CU respond poorly to punishmentRather, respond poorly to punishment under certain conditions

If a behavior is always rewarded and never punished, CU and non-CU equally able to change in response to stimuliIf a behavior is sometimes rewarded and sometimes punished, CU less able than non-CU to change in response to stimuli

Arguably best analogue to “real life”

Budhani & Blair, 2005

Hypothesis 2 (Cont.): Standard Treatment

Followed “best practice” for BT and emphasized:

Consistency in defining behavior and consequenceConsistency in applying definitions

Modified TreatmentInadvertently downplayed consistency

Labeling most misbehavior without applying consequence until it gets really serious arguably put kids in the “gray area”

Hypothesis 3: Lab tasks do not translate to clinical practice

Does punishment actually decrease performance / behavior in CU kids, or simply not help them as much?What do we mean by punishment?

Loss of something positive?Application of something negative?

Past research may underestimate effects of BT for children with CP-onlyImportant to assess CU in children with CP

CU traits common among children with CPNormally distributed within CP children

CPCU and CP-only differ in many important waysSuggests different etiological pathways

Children with CU traits seem to show a less positive response to behavior therapy

Reported in two independent, recent reviewsLess positive response does not mean lack of response

BT as necessary but not sufficient treatment

Promising treatment approachesIndividualized psychosocial treatments

Kolko & Pardini (2010)Supplementing BT with other approaches

Dadds et al (2012): Emotion recognition supplement to PT

Stimulant medicationWaschbusch et al (2007)Blader et al (2013)

PreventionHyde, Shaw et al (2011) – prevention approach

What do CU kids look like in “real life” settings – in school, with their peers, etc.?How do we best assess CU traits?

Optimal informant unclearParent, teachers don’t directly observe guiltChildren may be prone to dishonesty / deceit

Optimal method unclearExclusively ratings (but interview work beginning)

Inventory of Callous Unemotional (ICU) most used scaleRole of bias (halo effects, social desirability, etc.)

Lack of normative informationUnclear if dimensional vs. categorical conceptualization best fit

Why does stimulant medication work?Is med improving non-impulsively driven antisocial behaviors?Is medication acting through a different pathway in children with CU?

What’s the role of anger and impulsivity in CU?What’s the role of punishment

harm vs. not help CU kids?Add aversive vs. Take away positive?

What is role of parenting in CU?Can methodology account for extant findings?Are “non-traditional” parenting factors related?Do we need to look earlier in life?If not parenting, then what else?

What supplemental treatments should be tried?Moral reasoning?Guilt induction?Empathy improvement?

What is the role of manipulation in treatment?Setting clear limits vs. inducing a power struggleUse child’s need for control to advantage?Appeal to child’s self-interest

Contact info:Dan WaschbuschEmail: [email protected]

Documents

Daniel A. Waschbusch, Ph.D