We are delighted to have had the opportunity to speak to clinical psychologist Professor Mark Dadds, Director of the Child Behaviour Research Clinic at the University of Sydney, and winner of the 2020 ACAMH Eric Taylor Translation or Research into Practice Award.
It is the translation of research into practice that forms the main part of this interview. Mark discusses some of the intervention programmes that he has developed, many of these are world firsts. He details a theory driven intervention for children with callous unemotional traits, as well as school based early interventions and also family based programmes to tackle child anxiety. We also discover how he developed a range of assessment devices used globally for routine clinical and research practice such as the Griffith Empathy Measure.
We learn that a significant part of Mark’s work is understanding inter-parental processes whereby parental systems work together to maximise the child outcomes. Plus he explains how his research and clinical work tries to map human interpersonal processes, such as love and empathy, cooperation and coercion in order to build more effective treatments for children.
I am a clinical psychologist interested in the development of health versus psychopathology, especially common problems like aggression, antisocial behaviour, anxiety and depression. Originally trained in behavioural approaches to parent and family methods of maximising positive child development, I direct the Sydney Child Behaviour Research Clinic which operates as a clinical service for parents of children with developmental, behavioural and emotional problems, as well a training and research centre. A major thrust of this work is understanding interparental processes whereby parental systems work together to maximise child outcomes and their own health and happiness.
I also have a growing interest in how the parenting environment operates and gets trapped in, causal loops with fundamental biological characteristics of the child related to the major neurodevelopmental systems of dopamine, cortisol, serotonin, oxytocin, and vasopressin. To this extent, I have become increasingly interested in research and clinical work that tries to map our most human interpersonal processes such as love, empathy, cooperation and coercion onto the genetics and neural function of these major systems and builds them into new more efficacious treatments for young children.
Image and Bio from University of Sydney
Interviewer: Hello and welcome to the In-Conversation Podcast Series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today I’m interviewing Clinical Psychologist Mark Dadds. Director of the Child Behaviour Research Clinic at the University of Sydney.
Mark recently won the ACAMH Eric Taylor Translation or Research into Practice Award. He is particularly interested in the development of health versus psychopathology, especially common problems like aggression, anti-social behaviour, anxiety and depression. If you’re a fan of our In-Conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating review and do share with friends and colleagues.
Mark, welcome. Thank you for joining me and congratulations on your ACAMH award. Can you start with a brief introduction of who you are and what you do?
Professor Mark Dadds: I’m a Clinical Psychologist living in Sydney, Australia, and working at the University of Sydney, where I’m very lucky to be a Principal Research Fellow for the National Health and Medical Research Council of Australia and Director of Child Behaviour Research Clinic, which is an inner-city Sydney clinic that treats children from two to eight with all sorts of developmental and behavioural problems and increasingly treating kids from all over Australia and all over the world because we’ve largely gone online now with our treatment, both due to a need to do that just to get greater access and reach to our treatment, but also because of the pandemic, of course.
Interviewer: Mark, how did you come to be interested in child and adolescent mental health?
Professor Mark Dadds: I feel like I just drifted into it, to be quite honest. I was studying physics and so on at the University of Melbourne and I found it incredibly dry, and I can remember that my girlfriend at the time was studying psychology, and I found myself increasingly drifting over to her lectures. Loving the history of psychology and the history of medicine in general. First I changed to history of public health and germ theory and studied, kind of, epidemiology and general approaches to human health.
I became increasingly interested in mental health and then ran away from Melbourne with a band I was playing in and ended up in Queensland. While I’m here playing in this band I better keep studying. So I enrolled in psychology and then gradually drifted into clinical psychology and I was lucky enough to work with Matt Sanders. People will probably know Matt Sanders as the founder of the Triple P Programme and he became my supervisor when I was a PhD student, and yeah, that was it.
Interviewer: Mark, you won the ACAMH Eric Taylor Translational Research into Practice Ward, which I understand you collected live at 4am from Sydney at the ceremony broadcast from London. You’ve made an extraordinary contribution to the science of child mental health through original innovative research translated into interventional programmes that are implemented worldwide. Translating research into practice is often an area that researchers struggle with. How have you managed to be so successful at this?
Professor Mark Dadds: Well, I think in a way I’ve just been very lucky. I’ve been able to always keep one foot in the clinical care and one foot in the research camp and by having a research fellowship with the NHMRC in Australia I’m incredibly lucky that my time is free to be a full time clinical researcher. Secondly, I was raised in an environment of the scientist practitioner, where the science was really not much point unless you were really invested in some real world problem, and my supervisor used to always say to me, you can tell this person’s articles that they’ve never actually seen a child without a reasonable research. You can just tell.
I always have kept treating families and children all the way through my career. So I’ve always had an eye on the actual clinical practice. Research has always been informed by that, and I suppose the third influence on me, which was very interesting, was back in the 70s when I studied, certain people at the University of Melbourne looked at China as a revolution, as a role model, when we probably didn’t know about some of the horrors that occurred then, but the idea of the barefoot doctors was a model that I was raised into, which is that the researchers have to go back into the fields and if you’re a doctor you should be a barefoot doctor.
You have to go back to the village and live there and understand the problems of the village in order to be a true researcher and expert and so on.
Interviewer: And that translation into practice, why is it so important in particular when it comes to child and adolescent mental health?
Professor Mark Dadds: Oh, look, that’s a fabulous question. When I started back in the 80s and so on in Australia, and it would have been the same in the UK if you had a child who had early onset mental health problems or behavioural and emotional issues and you took them to a clinic, what was most likely to happen was that you would have been left outside and the child would have been taken in and some sort of play therapy would have occurred and the therapist would have been trying to get the child to express their deeper inner conflicts and so on.
And also, as a parent, you probably would have been seen as to blame for the problem. There’s almost no evidence that this approach work, and in fact in my experience it can make things a lot better because the parents become disenfranchised from the process. The child is just being reinforced for expressing problems and so on like that. So we’ve seen a massive shift in just a few decades towards evidence based practice, and with kids these interventions actually can do really, really positive good and they can do positive harm.
In my experience much more than with adults. So it’s incredibly important that we do things that actually help rather than just what we think helps.
Interviewer: I want to focus on some of the intervention programmes that you’ve developed, and many of these are world first. One is a theory driven intervention for children with callous, unemotional traits. What can you tell us about that programme?
Professor Mark Dadds: This is a really challenging one. The most common treatment that certainly I do and it’s done all over the world involves training parents in positive parenting strategies for children with aggressive antisocial behaviour, and this is one of the great achievements of the behavioural sciences. While it doesn’t work in every case, it works in most cases, and these children show wonderful improvements. Most of the kids with that sort of behaviour problem tend to be quite emotional and dysregulated, but there are still kids that are the opposite.
They’re quite unemotional, callous and they’re lacking in empathy and so on. These kids don’t do so well. They’re less susceptible, if you like, to the quality of parenting that they’re receiving. So we’ve been trying to work on a treatment for that. Really the essence of this treatment is that these children are somewhat insensitive to other people’s emotion. So we believe that that makes them very difficult to parent, and one of the ways that they are less sensitive is that they don’t engage with other people’s emotions, look into their eyes, resonate with how they feel and so on.
So what we’ve been doing is trying to keep the solid foundation of these positive parent training programmes, but add in elements, very carefully that address these kids lack of empathy and so on. We’ve shown that these kids definitely show this, kind of, lack of engagement with other people’s emotions, but our ability to shift this is proving quite difficult I have to say. We’ve been able to get really short, powerful changes in these kids’ interest in other people’s emotions, but we’re finding that it goes back to where one after treatment, but we do still get behaviour change in their antisocial behaviour, but it’s just harder getting change in the callous traits in these children.
At conferences where I’ve spoken about this, I’ve had some people say, Mark, what does it matter if they’re not being antisocial anymore? Who cares if they’re callous? I’m like nice point, but on the other hand it’s kind of like, well, if they’re still callous but they’re not showing any social behaviour, maybe just they’re being more successful in their callousness. So it’s a very interesting issue. It’s a story that isn’t finished yet.
Interviewer: In 2019 you co-authored a paper published in the Journal of Child Psychology and Psychiatry, the JCPP, evaluating that programme. Can you say anything more about the actual findings of the research?
Professor Mark Dadds: In terms of the effects of the positive parenting on the children’s behaviour we got really wonderful effects. The majority of these kids showed significant improvements in their antisocial conduct problem behaviour. The parents were very happy with the kid’s behaviour and so on, but we didn’t get any bang for our buck by adding in the component where we focussed on what we call this kind of love engagement where they look into each other’s eyes. We train the kids how to recognise emotions in other people. How to care about those emotions and all that.
We felt that adding that it didn’t really add much benefit over and above, just getting the mom and the dad to spend quality time with the child each day. It’s possible that that’s what the story is, that if you do the positive parenting programme, but you also spend lots of quality time, like trying to engage and express love, reciprocated love with these kids it’s enough to change their antisocial behaviour, but as I said, the depressing part was even though we got big shifts in their callousness at the end of treatment they were still in the high level range on callous and emotional traits.
Interviewer: Mark, let’s turn to some of your other interventions. You have programmes which are school based, early interventions and also family based programmes to tackle child anxiety. Can you tell us some more about these interventions?
Professor Mark Dadds: Well, these are, again, another wonderful success of the clinical psychology and psychiatry. When I started behavioural programmes focussed on anxious kids, which were pretty much about just exposing the child, kind of get back on the horse approach, if you like. We knew that that approach was the best way to go, but there were really no packaged disseminator ball programmes that were readily available for these kids. Philip Kendall in the USA in Philadelphia developed a programme called the Open Test, which was really one of these programmes that packaged this cognitive behavioural approach with children into a manualised treatment.
We took that in Australia and turned that into what we called the coping koala at that point, and it was an approach that really leveraged the parents and trained the parents in how to work with their kids in that regard and so on, and that became a very successful treatment. In the late 1990s I thought we need to have this as a school based preventative strategy. We went into the schools and we screened the schools in a way that was hopefully not at all stigmatising for the children.
We identified the kids that were at risk for anxiety problems and we ran a fun kind of after school programme and it was really lovely. We got a fix up until two years where the rates of anxiety disorders were lower in those kids than those that hadn’t received it.
Interviewer: Mark, a major focus of your work is understanding inter-parental processes whereby parental systems work together to maximise the child outcomes. Can you tell me more about this aspect of your work?
Professor Mark Dadds: This was really the first thing that I did. When I first started working with Matt Sanders in Queensland my focus was on how the parents worked together or don’t work together when you do these positive parent training programmes. I was struck clinically by just how many parents were suffering from really quite problematic levels of conflict with their spouses, and when it came to parenting it was very common for one parent to identify as the tough one. One as the softy and every time there would be a child behaviour problem it would really escalate into the marital relationship, if you like.
So there’s just this conflict spreading throughout the family, and what I discovered was that when parents are not working as a team these parenting programmes don’t work very well. So it’s really, really critical that parents are engaged together and work as a team. Now, when I started, it was basically just mums coming in to get these positive parenting training programmes, which we knew very little about then and very often she was going home to an environment in which the changes she was trying to make were just being ignored or the dad was hostile to them.
And we found that you don’t really need to go into, kind of, deep intensity of marital therapy with all of these families. If you just call a moratorium on the marital problems, invite them to work as a team, put their own thing aside, get the child’s behaviour under control for a lot of these families they go, oh, my goodness, that’s the first time we’ve achieved something together in ages and then we try and get them back dating again.
You know, and it actually can be a way of repairing problematic or exhausted marital relationships through these positive parenting programmes.
Interviewer: You mentioned dads, I want to go back to dads and you talked about how originally it was nearly always the mums that would turn up. What’s the situation now? How involved are fathers and why is their involvement so important when it comes to child mental health?
Professor Mark Dadds: So this is a wonderful question. As I said back in the day, it was really just mums and the evidence was in the positive parent training programmes all around the world the fathers were really not getting involved, and if you look at something, in Australia we have a thing called the Raising Children Network online, which is a resource online, and it has tens and tens of thousands of people go to that website every day seeking help, and still the vast majority of those are women, but men are slowly increasing their interest and their engagement at this level.
Now, in 2018, I think it might have been, I went to Movember Foundation and said, you know, do you realise that most problems of regression are in young boys? The ones that are seeking help for this are the mums and the people they are seeing to get help are mostly young women psychologists. So you’ve got a problem of male aggression being almost solely addressed by women in our society and it’s time that the men step up. Movember resonated with this and funded us for the like father like son project, which we devoted to collecting data on fathers engagement, speaking with fathers, developing programmes for them and so on.
When fathers participate in these positive parent training programmes you get a jump up in their effectiveness. Now that doesn’t mean that they work for single parents and so on or a parent that does it on their own.
Interviewer: In terms of father participation, how have you increased participation? How have you made them accessible?
Professor Mark Dadds: We first spoke to practitioners and fathers about what they wanted and what would have worked, and it was pretty simple. The father said, Number one, we want to be involved. Number two, we want to know that this stuff works. We don’t want it to be just, you know, nonsense. We want to be straight to the point of brief and we want to feel welcome. We want to feel that it speaks their language, you know, because for a lot of men they felt like if they were coming to these programmes they were really entering some kind of foreign nation of women that they didn’t feel comfortable with, and it was very interesting, I should say.
Then when we spoke to a lot of the young practitioners, all we’d say to them was fathers, what do you think of our fathers, and do you know what the first thing that would come into their mind was abuse, alcohol, family violence and we’d be like, oh, my goodness me. So we decided to try and make resources that were father friendly, spoke their language, were effective, could be accessed online and so on.
We trained practitioners in how to speak, kind of, dads speak, if you like, and we’ve shown that this is leading to a big improvement in father engagement in these programmes. So when we did the parent work study, which was designed to be father friendly, we got 50% fathers, 50% mothers engaged in that. Now, just back to your question. How do we get them involved? It was really through media campaigns. We went into all the traditional media, went through social media and spread the word.
Interviewer: It also sounds as if there had to be work around changing attitudes of the practitioners. You said as soon as you mentioned the word dad they would think of abuse and alcohol and so on. So fathers were kind of judged before they even participated.
Professor Mark Dadds: Yeah, I found this really, really interesting and we set up a practitioner training programme because we had already developed a model for how to engage all parents that were feeling like they didn’t want to be there. We had a nice little system for how to listen to them. How to make them feel welcome and so on. Now we implemented that and we turned it into an online training programme for practitioners. It only took two hours and it was simply how to speak to fathers and so on, and we got really lovely results from that in terms of improvements in practitioner confidence. Willingness to work with fathers now. Now it’s interesting, though, this also involves systems change because traditionally the mental health systems were set up to run from nine to five when most work and couldn’t really get away.
You had young female practitioners working nine to five. They felt a little bit uncomfortable with some of the hours. It was probably in a way easier for them to just work those hours and have mums coming in during the day, if you like. So we had the whole system geared up to making it very difficult for fathers to access these treatments.
Not only have we trained the practitioners, but we’re proud to say you need to gear up your whole system so that it has flexible hours or flexible access through online engagement and so on. Be ready to talk to fathers and welcome them in and let them know this is an evidence based treatment and that they are part of the solution.
Interviewer: Mark, you’ve also developed a range of assessment devices used globally for routine clinical and research practice such as the Griffith Empathy Measure. Can you tell us about these devices?
Professor Mark Dadds: I should probably say that while we developed them, many of them escaped, if you like, into the world rather than were deliberately released. It’s an interesting story, and I’m sure a lot of other people have had this experience. We developed a little measure that we needed for one particular purpose. So, for example, the GEM, the Griffith Empathy Measure. We needed to be able to measure empathy in our kids. So we developed a little measure and before we got it right, this thing kind of was out and had been escaped into the world and people were using it all over the world. II think the GEM now has been translated into about a dozen languages, but recently I was criticised by someone that this measure doesn’t do all we would hope it would do, which I actually agree with. It’s true. So these things are not bad little measures, but of course, they could always be better.
But the ones we’ve done are the Griffith Empathy Measure which was quite new in measuring empathy in that way. We’ve done a few in measuring marital conflict. You know, what we spoke about before. Can parents work as a partnership when bringing up their children? Now that one was called the parent problem checklist, which is used quite extensively now.
Interviewer: Mark, you’re interested in research and clinical work that tries to map human interpersonal processes, such as love and empathy, cooperation and coercion onto the genetics and neural function of the systems that underpin our behaviours in order to build more effective treatments for children. What is the latest in this area and your involvement in it?
Professor Mark Dadds: I got really, really interested in the biological side of things, especially genetics and epigenetics about 15 years ago, when there was a big hope in those days that understanding the genome was going to make a significant contribution to our understanding of complex human processes. I would say at this point that it hasn’t done that. That the structure of the genome has provided very little understanding of anything so far, except for us to know that the way we are and when we are healthy and unhealthy it’s very unlikely to be able to be found in terms of just the typical genetics of our DNA.
However, the epigenetic processes, if you like, in terms of how the DNA is converted into us, how it’s converted into proteins, and then how those proteins are formed into complex chemical processes that inform health versus para-physiology is becoming, I think, a very exciting process. So if you take the example of epigenetic processes, we know now that the way the genome is converted into our function has quite strong and reliable implications for the kind of people we are.
We have shown that the way that certain genes are turned up in volume or turned down in volume through a process called methylation affects the way the child expresses behavioural and emotional problems, and so if you take a gene like the oxytocin gene transcribes receptors for oxytocin, which is involved in everything from childbirth to looking at other people’s eyes, empathy, pair bonding and so on, that gene can be turned up or down by methylation processes, and kids that are low on empathy and concern for other people tend to have that receptor gene turned down in volume.
These discoveries, I think, are very, very important. The question is what’s the psychological process that are impacting on the dampening or the regulating of these particular gene? I think this is just a wonderful new field where we need the psychologists to be speaking to the pathophysiologists, the geneticist and so on about integrating those two models. How can we make sense of critical things in our life, like love, tenderness, violence and so on and how do they turn particular gene expression up versus turn it down in the developing child?
Interviewer: Do you see it as reversible, though?
Professor Mark Dadds: Oh, I think the evidence says that it is reversible. Yes, I think there will be processes that get the gene expressions back up again. What they are and how we can do that we’re only at the beginning of answering that. The one we’ve been playing with in fact, this was the one that was in the Journal of Child Psychology and Psychiatry paper you referred to before. That process with the Kalis children that we’ve been experimenting with is really about love and reciprocated eye gaze.
I think this is one of the critical human processes that begins at birth, and I think that it’s a very powerful expression of the deepest parts of who we are, and I think that it’s involved with hormones like oxytocin, and I think that engaging in that kind of close, reciprocated love eye gaze actually teaches the child to imitate, to pay attention and so on, and probably up regulates some of the genes necessary for doing that.
Interviewer: How far away do you think we are then from having a much greater grasp on it?
Professor Mark Dadds: I think it’s still going to take a decade or so. The trouble with this work is that it just takes really large, quite expensive studies. You know, I’ve been so lucky to be able to have been supported to do some of this research, but it’s outside of the realm of most people because you’ve got to not only be working with kids in clinics and have access to them, but you’ve got to be able to have an understanding of the genetics.
You’ve got to have the ability to collect human samples and so on. This is just complicated research that involves cutting across multiple disciplines and so on.
Interviewer: Mark, what else are you working on currently?
Professor Mark Dadds: To be quite honest my great love at the moment is making fine furniture, but that’s probably not the best thing to talk about, or the other one is playing in my little jazz band. That’s what I’m working on. I love those, but if we stay with psychology at the moment, I feel very lucky to have three studies about to come out. The first one is that we’re checking whether our positive parenting training programme does change the chance, our genetics. That’s going to be very exciting.
We’ll be finishing that this year. We’ve also been following a large group of children through for three years from birth to have a look at how they develop attention to other people’s emotions and so on. Finally, we’re funded at the moment to be evaluating a treatment for autism, childhood autism that brings together what we think are three critical ingredients in these children’s development, brings them together into one package for the first time. So we’re evaluating what the effects of that on development of autism in kids.
Interviewer: Can you say what the three things are?
Professor Mark Dadds: Now, none of these are particularly original, but it’s the first time they’ve been put together in one package, and I am interested in whether these things work synergistically, if you like, if they enhance the effects of each other. So when we work with the kids, the first thing you need to do with a child that’s struggling and has autism is help them get rid of any aggressive, aberrant type behaviours they have. Repetitive behaviours, hurting themselves, hitting other people.
These sorts of things, reduce that and increase the rate at which they have positive engagement and self-regulation and so on. So the first one is like a behavioural programme, people will know that as like an ABA approach. Second element is use these parent child social communication interventions, which have been developed pretty much very nicely by UK groups. Jonathan Green have been doing wonderful work with developing these social communicative interventions, but once you’ve got the child’s behaviour improving a little bit, train up the parents in spending time with the child and working on their engagement, their reciprocation as so on.
So our third element is to do our inter-parental support programme and marital teamwork type things and this comes back, you’ll hear with my general interest, but a lot of these parents are really struggling. You know, it’s really hard to raise children with developmental problems like this. Very few people ever talk to them about how they’re coping. Now, our hypothesis is, if you do them in that order, the ABA, the social communicative, the more general parent mental health that we’re hoping that we can see some sustained changes in these kids and their family.
Interviewer: Mark, is there anything else in the pipeline that you’d like to mention?
Professor Mark Dadds: The other one is that we have applied for a large grant in Australia to introduce a national system for child mental health called Growing Minds Australia. This is my dream really. It’s probably my swansong, and that is that we have a system where it’s like a co-operative empowerment, mental health for the whole country and when you have kids you sign your family up to be an empowered member of the club and this gives you access to online mental health check-ups, and the best possible evidence based support in terms of this is what my health at this point for this problem, etc., where we have a like a clearing-house for all of the best online treatments. So rather than it just being this piecemeal, relying on parents, identifying problems and knowing where to go, we finally have a unified mental health system.
Interviewer: Brilliant, and finally, Mark, what is your take home message for those listening to our conversation?
Professor Mark Dadds: In this world where nonsense can float to the top and have so much impact on people’s lives I would just like to say we need science more than ever. We need evidence based approaches more than ever, but we also need evidence based approaches that speak to everyday problems. The barefoot doctor approach, if you like. The research that gets back out into the field and addresses problems that are common and need addressing.
Interviewer: Mark, thank you so much. For more details on Mark Dadds please visit the ACAMH website www.acamh.orgorg and Twitter at ACAMH. ACAMH is spelt ACAMH, and don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoy the podcast with a rating or overview and do share with friends and colleagues.