2 hours ago
4
There can be an air of inevitability to how we talk about psychopaths – that old-fashioned “bad seed” theory that purports the antisocial, manipulative or even violent are born that way and destined to do harm.
But Professor Eva Kimonis, a clinical psychologist and director of the University of NSW’s Parent-Child Research Clinic, has seen first-hand that the road to psychopathy isn’t necessarily predetermined – if intervention arrives early enough.
Kimonis works with children with challenging behaviours, including those displaying “callous-unemotional traits” or “limited prosocial emotions”, which can be precursors of psychopathy in adulthood (psychopathy is a diagnosis only given to adults).
She has just published a book, A Clinical Guide to Working with Youth with Conduct Disorders and Limited Prosocial Emotions, which she hopes will fill a gap in diagnostic understanding and evidence-based treatment.
By the time children arrive in her care, she says, many have been misdiagnosed with autism or with pathological demand avoidance, which involves an extreme resistance to everyday demands and requests.
A correct diagnosis means families can access the right treatment, lessening the load on the healthcare system and, ultimately, changing the course of children’s lives.
“Our kids have significant impairment,” Kimonis says. “Many of them can’t function at home or school. They get kicked out of daycares or preschools. Their parents are left to figure out how they’re going to work while also taking care of their kid.
“They often aren’t allowed to go to mainstream schools any more … many of them we know never finish high school or go off to college, and just become entangled in the justice system.”
While up to 1 per cent of the global population is estimated to be psychopaths, this figure rises to between 15 and 25 per cent for the incarcerated population – meaning the work of researchers like Kimonis could have far-reaching implications.
What are callous-unemotional traits?
Mark Dadds, a clinical psychologist at the University of Sydney’s Child Behaviour Research Clinic, was at the forefront of early research into children with callous-unemotional traits. (Dadds worked alongside prominent American child psychologist Paul Frick, Kimonis’ PhD supervisor.)
“Originally, the psychology paid no attention to these kids,” Dadds says. “The interest came because myself and a bunch of other people were treating conduct disorder – kids with chronic problems of aggression, emotional dysregulation, not following instructions, etc.”
While all children exhibit these traits to some extent, of course, those with conduct disorder do so every day. Working with these kids, Dadds and his colleagues began to notice a delineation.
“Rather than it being the traditional, ‘they’re just immature, and they have to learn to regulate their emotions and co-operate’, some of them were actually a bit cold and callous,” he says.
“So what happened is the tradition of psychopathy – the ideas of psychopathy – got downloaded into children for the first time.”
Today, callous-unemotional traits are considered a subset of conduct disorder. There are four characteristics, formally identified by criteria in the standard reference manual used by mental health professionals, the DSM-5-TR, that Kimonis says can be reliably spotted from the age of three (although she and her team are working to see if they can be identified earlier):
- Lack of remorse or guilt.
- Callous lack of empathy.
- Unconcern about performance.
- Shallow or deficient emotion.
The behaviour of those with callous-unemotional traits can manifest in ways similar to other conduct disorders, like aggression, destruction, lying and stealing.
Why?
So why do some children exhibit these traits? Kimonis says evidence suggests two key components.
First, children with callous traits have a core deficit in how their brains process emotions. “We’ve done research that shows that when they see someone crying or hurt, it’s not capturing their attention – so their minds aren’t wired for that emotional information to be important,” she says.
The second part lies in how parents respond to their children.
“It’s this vicious cycle – it’s so hard being a parent, but these parents are not getting much back emotionally from their children or with any interest from their child or eye contact or even a response to their distress or upset,” she says.
“It is a cycle where the parents start to withdraw, and the problem with that is these children’s brains aren’t processing emotional signals as it is, but now they’re getting fewer emotion signals because their parents are withdrawing.”
Kimonis references a British study of five-week old infants which found infants’ preference for faces over objects and mothers responding more sensitively to their babies during playtime was associated with lower levels of callous and unemotional behaviour in toddlerhood.
The ‘gold-standard’ therapy
At her research clinic, Kimonis works with families using parent-child interaction therapy, which has existed since the 1970s and is still widely considered the gold standard in treating children with limited prosocial emotions.
“These kids are a bit harder to treat,” says Dadds. “But it’s funny after all the decades of work we’ve done, still the most effective treatment we know for these kids is positive parenting, where the parents are empowered to find ways to love these kids, give them lots of positive rewards and use effective discipline with them. And often that means helping the parents with their own struggles to be able to do that.”
The first stage of Kimonis’ treatment works on parental warmth. “That’s a bit of a vague term,” she says. “So we’ve done a lot of science to try and understand, what is parent warmth and how is it different for children with callous and unemotional traits.”
“It’s facing the child when you talk; it’s using modulation in your tone of voice; it’s eye contact; it’s smiling and having positive affect when you’re interacting with a child; it’s responding to their needs; it’s thinking positive things about them and not thinking of them in a really negative light.”
To do this, Kimonis guides parents from behind a one-way mirror, speaking to them through an earpiece as they interact with their child.
The second stage focuses on rewards, which Kimonis says children with callous-unemotional traits are extremely sensitive to. (Conversely, punishment, which they are traditionally more likely to encounter, has little influence on them.)
“We developed this individualised token system where the child gets to earn tokens, that they can trade in for things that really interest them, for doing the right behaviours – things like listening to the parent or being gentle or prosocial,” says Kimonis.
The final stage involves a therapist sitting down with parent and child. “That would be like, teaching about micro expressions. So when a person is sad or afraid, what are the parts of their face doing? So we can really learn the building blocks of understanding emotions, and from there we go to, what does the body do when we’re feeling certain ways, what situations make us feel certain emotions, and then we start to talk about what are appropriate behaviours to do when people are experiencing different emotions.
“It’s empathy and emotion training, to teach the child the things they are struggling the most with.”
While evidence shows Kimonis’ adaptation of parent-child interaction therapy is the most effective treatment for children with conduct disorders and limited prosocial emotions, Kimonis says significant barriers remain – including limited availability, accessibility and acceptability.
She has been working with NSW public schools to tackle this problem by delivering early intervention at school.
“You really see what we call a sync between parent and child where they were really disconnected – it’s almost like this flow. It’s a nice thing to watch between them when they go through treatment and understand each other.”
Make the most of your health, relationships, fitness and nutrition with our Live Well newsletter. Get it in your inbox every Monday.
