In this Papers Podcast, Dr. Christina Stadler discuss her co-authored JCPP paper ‘START NOW: a cognitive behavioral skills training for adolescent girls with conduct or oppositional defiant disorder – a randomized clinical trial’ (https://doi.org/10.1111/jcpp.13896).
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- Why the researchers decided to undertake the intervention (START NOW) in youth welfare institutions.
- Insight into START NOW, a cognitive-behavioural, dialectical behaviour therapy-oriented skills training program.
- The methodological challenges in undertaking this randomized control trial.
- Implications for practitioners, and messages for parents and carers.
- Potential areas of further investigation with regards to the START NOW intervention.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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My special interest lies in investigating the underlying neurobiological mechanisms of deficits in emotion processing in mental health disorders, e.g. Disruptive Behaviour Disorders or autism. From my clinical experience it seems evident that for example children and youths with Disruptive Behaviour Disorder have difficulties in understanding and regulating their emotions. However, as these children are characterized by a very heterogeneous symptomatology, my team aims to clarify whether specific neurocognitive and neurobiological correlates are related to various clinical subtypes, e.g. hot-tempered or cold-blooded aggression. In cooperation with national and international experts in the field (see for example (www.femNAT-cd.eu) we investigate the interplay between psychosocial and neurobiological risk factors on maladjustment in patients and in typically developing adolescents by using psychophysiological, endocrinological and neurocognitive assessment tools as well as innovative brain imaging techniques, both in cross-sectional and longitudinal approaches. We are also highly interested in developing more tailored intervention approaches and to test their efficacy in regard to neural correlates of emotion processing. Due to the promising results of our recent randomized control trial with our START NOW cognitive-behavioural skills training program (https://istartnow.ch), we currently develop a web-based version which is tested in youth welfare institutions and forensic institutions as there is a strong need for innovative and economic intervention approaches. (Image and bio from University of Basel)
Transcript
[00:00:01.310] Mark Tebbs: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, and I’m a Freelance Consultant.
Today, I’m really pleased to be talking with Dr. Christina Stadler, who’s the Lead Author of a paper entitled, “START NOW: A Cognitive Behavioral Skills Training for Adolescent Girls with Conduct or Oppositional Defiant Disorder – a Randomized Clinical Trial,” recently published in the Journal of Child Psychology and Psychiatry. Christina, thank you for joining me. Really looking forward to our conversation today.
[00:00:38.579] Professor Christina Stadler: Oh, thank you for having me. It’s a pleasure to talk about our study and our research.
[00:00:43.770] Mark Tebbs: Brilliant. So, let’s start with introductions. Could you introduce yourself and the people that you worked with on the paper?
[00:00:50.720] Professor Christina Stadler: I’m a Professor for Developmental Psychiatry at the University of Basel, working at the Clinic for Children and Adolescents, at the Psychiatric Hospital. This means I’m a Researcher on the one hand, but I also work as a Clinician. Originally, I studied psychology, and from the beginning of my study and training in psychotherapy, I always was interested to better understand aggressive and impulsive behaviour. And in my research, I focus on investigating why children have problems in emotion processing and emotion regulation, and how we can support them and their families.
And yes, you asked me about the people who worked with me on the paper. They all have been involved in this huge research programme on conduct disorder, and this project was funded by the European Commission. And there we had a cross-sectional study, a longitudinal study, and also, this randomized controlled trial, and I was the PI of this RCT. The RCT was conducted in Switzerland, the Netherlands, and Germany, and, therefore, there are so many people on this paper. And Linda, the last author, was my PhD student, and she co-ordinated this international, multisite study, which quite often, was really challenging, and Marietta, the co-shared last author, did all the statistic.
And I would like to mention author Nora Raschle, and she investigated the neural mechanisms in CD girls, and we were also interested in the question whether START NOW training has an impact on neural function, or what predicts treatment based on a neural level. And Bob Trestman is the person who originally developed START NOW, he developed it for the forensic settings in the United States, and where he – I have a good co-operation with him, and he helped us to adapt this training for young people.
[00:02:42.840] Mark Tebbs: Excellent. Really looking forward to getting into the detail of the paper. So, let’s turn to it. If you could start by just giving us a brief overview of the, kind of, aims of the study, it’d be really interesting to unpick why you decided to undertake the interventions in the youth welfare institutions.
[00:03:00.440] Professor Christina Stadler: Our main objective was to investigate whether a cognitive behavioural skills training, the name is START NOW, would be effective to reduce aggressive behaviour in young people aged 14 to 19. And all participants had to fulfil a diagnosis of either conduct disorder or oppositional defiant disorder. And these childrens with such a diagnosis are characterised by high aggressive, destructive behaviour and severe emotional and behavioural dysregulation, sometimes, also, a lack of empathy, or resistant, a lot of opposition in daily life. And you have to know that the rate of CD and ODD in youth welfare institution is much higher compared to normal settings. Studies indicate a prevalence from about 60 to 80%.
So, I would say there – or we said that there’s really a need to bring promising interventions to these settings and, therefore, this was the reason why we conducted this RCT in youth welfare institutions. Maybe it’s also important to know that in the – in this study, but also in the whole EU project, we focused on girls, on girls with CD and ODD. And the reason for this is that we do not know so much about females with conduct disorders. Most of the studies have been conducted in males, but there seems to be a gender paradox that means that in case females fulfil the criteria for CD, they often are more affected than boys. So, that’s interesting, and therefore, we did this study in females.
[00:04:37.320] Mark Tebbs: Okay, and could you tell us what is START NOW?
[00:04:41.240] Professor Christina Stadler: START NOW is a skills training. The foundation of START NOW is cognitive – comes from cognitive behavioural therapy, but it’s also influenced by DBT, dialectic behaviour therapy. And one of the main characteristics of START NOW is that we use many illustrations, comics and film clips. In the skills training, there’s a workbook for the adolescents, and we have included this to make it more attractive for young people, who are not so often motivated to participate in a intervention. And in the United States that now has been already shown to be effective, but it was never tested within a randomized controlled trial.
And in this version of START NOW, we had a 12 weekly group session, plus individual sessions. And each session is highly structured and compromises, for example, mindfulness exercises, functional analysis of emotion and behaviour, as well as specific topics, such as, accepting – learning to accept emotions, building up interpersonal skills or setting goals. All these things they have to be learnt by the young people. But you have to know that the skills training was provided by the staff in their respective institution. Thus, we provided a two days pre-training, where we taught the staff how to run the sessions. We also trained them, for example, also, how to use motivational interviewing techniques that have been shown effective to elicit behavioural change, because most of the young people are not motivated to change behaviour.
So, the overall goal is that staff is enabled to better deal with aggressive behaviour, to have strategies to deal with these adolescents, and that they can provide the skills training in the institution.
[00:06:37.800] Mark Tebbs: So, yeah, it sounds like a really, potentially, accessible way of delivering effective interventions. Could you turn to the methodology? How did you go about the randomized controlled trial, and were there any particular methodological challenges that you had to overcome?
[00:06:53.110] Professor Christina Stadler: That’s a interesting question. You know that the study aimed to evaluate how efficient is the skills training START NOW, and we compared this to standard care in youth welfare settings. So, what’s standard care? Standard care means, for example, music or art groups, individual support, individual psychotherapy, even pharmacotherapy. So, there’s a lot of things that are provided in welfare institutions. So, we asked, what has, in addition, this START NOW training an effect? So, we used randomized ABBA design, meaning that we randomized an institution either to begin with START NOW, or we randomized the institution to the control group.
And I can say that conducting this kind of research in the field is rare. It’s not done so often, but it’s of major interest, because whether intervention is effective in the real world and not only in highly controlled conditions, like an university setting, is quite important. So, institutions that were in the control group were offered the intervention after the end of the assessment, so after the follow-up, but sometimes they were quite frustrated because they couldn’t start and they have to wait a long time. And it was not always easy to convince institutions to participate in our research project, but this is good scientific standard, and at the end, I’m quite happy that we had enough institutions that were willing to participate.
One recommendation I would give to Researchers is not to overload a study. I think that was a challenge. We were so ambitious in our EU project. We had a lot of research questions, so we had also a lot of questionnaires that we gave to the girls, and they often were not motivated to fill them out. So, that would be my recommendation, if you do a study in the field, it has to be feasible to do it and not to overload it. I think it was a burden sometimes for the participants to fill out so many questionnaires.
[00:08:59.950] Mark Tebbs: Yeah, I can imagine. So, could you tell us, what were the main hypotheses that you were trying to test?
[00:09:06.279] Professor Christina Stadler: The main question we tried to answer was whether females participating in this add-on START NOW training would show a greater reduction in aggressive and oppositional behaviour, compared to those adolescents who received only the standard care, so the control group. And we were interested in the change of CD/ODD symptoms from pre-assessment to post-assessment, and we were also interested in the change of symptoms from pre-assessment to follow-up. Post-assessment was done directly after the end of the last of the 12 group sessions, and the follow-up assessment was done 12 weeks after the end of the intervention.
Thus, the change in CD/ODD symptoms was our primary outcome measure, and this was assessed within a semi-structured psychiatric interview. We used the Kiddie-SADS. And this interview was done separately with the girls, and with a Social Worker, who was, if possible, not involved in the intervention. Besides the interview, staff also rated aggressive behaviour in daily life, parents rated girls’ irritability, and girls also rated mental health problems. So, they had a – some self-questionnaires in addition. And we were also interested how satisfied were the girls with the training, and how satisfied were the trainers providing the skills training.
[00:10:34.480] Mark Tebbs: Okay, so what did you find?
[00:10:37.450] Professor Christina Stadler: Yeah, so, our research indicate all participants showed less CD and OD [means ODD] symptoms after the 12 weeks. So, both the girls in the – who received standard care, and those who received, in addition, START NOW. So, there was no significant group difference directly after the intervention regarding our primary outcome measure. Yet, in regard to secondary endpoints, there was some indication for less aggressive behaviour that was rated by the staff and less irritability.
But we have to focus on the primary outcome measure, first of all. We did find a greater symptom reduction compared to standard care at follow-up assessment. So, not directly at the end of the intervention, but at follow-up, and this is a medium effect size. So, that is interesting, and what does this mean? It means that 12 weeks after end of the training, participants who received START NOW further improved, and we only found a further decline in CD/ODD symptoms in those girls who received START NOW, and not in those who only received standard care.
[00:11:54.240] Mark Tebbs: Okay, so, how have you interpreted that finding?
[00:11:57.950] Professor Christina Stadler: Yeah, we discussed this a lot, and first of all, you could say that maybe a skills training that is provided only for 12 week is too short to have an effect in the United States, so Bob Trestman is doing more sessions. But it’s important to mention, as I mentioned it already, that at follow-up, there was a significant difference, also, in our primary outcome. And this is what we have also discussed in detail in our group, and it seems that this is a delayed treatment effect that may, due to further improvement in adolescents’ care on the one hand, but this delayed treatment effect could also be related to the fact that staff was better skilled to, yeah, to support adolescent girls in problematic situations, and that the staff applied skills that they learnt in pre-training also beyond this 12 week group training. I think this is a important aspect that we have to considered.
For example, what was really helpful, and that was the information that they gave us, that the motivational interviewing techniques are really useful, and maybe they learnt how to use these motivational interviewing techniques to engage girls to change behaviour. And, also, this in-vivo coaching I think is very important, and I would suggest that they applied all these skills beyond the skills training. So, their skills also probably improved, yeah.
[00:13:34.290] Mark Tebbs: Yeah, okay, and was there any aspects of the results that, kind of, surprised you?
[00:13:40.820] Professor Christina Stadler: Yeah, what surprised me most is the fact how severely affected are those adolescents with conduct disorder placed in the youth welfare institutions. So, accordingly to our DSM diagnosis, four symptoms are sufficient to fulfil the diagnosis of CD or ODD, and the average number of symptoms at pre-assessment was about nine to ten. So, that really indicates that they are severely affected, and often, there are up to three other comorbid disorder they have.
So, in general, I would say that the burden in affected children and families is extremely high, and CD is predictive for poor mental and physical health, it – for school dropout, criminal behaviour, even premature mortality, and in girls, there’s a high risk factor for early pregnancy. I’m really wondering why this disorder still often is so neglected. We need to put far much effort to bring evidence-based care to these children and young people and support the setting, Social Workers, Teachers and parents. That’s the main issue, I think.
[00:14:51.540] Mark Tebbs: I’m wondering what the implications of the study are from the practitioner point of view.
[00:14:57.040] Professor Christina Stadler: I would say that intervention, as START NOW, can be, or are positive approach. They are CBT-oriented, derived from DBT. They aim to focus on improving emotion regulation. And I think this is important to focus on improving emotion regulation, because that’s what we also found in our EU project, we have investigated, that’s what’s done by Nora Raschle, how is the brain function in these girls? And what we found is that those area in the brain that are responsible for emotion processing and emotion regulation are deficient in those girls. And therefore, I’m so interested in the results of our study that is ahead for publication, whether the START NOW training also has an impact on brain functioning in these girls.
Sometimes Clinicians are still resistant to use skills training for these kids with disruptive behaviour, because they discuss maybe children who are in a group session might be negatively influenced by each other. They learn problematic behaviour. I do not share this opinion, and I would say that our results show something different. Skills training can be effective, probably we need sufficient – a sufficient number of sessions, and especially then when they are embedded in the setting where the children live. Simply learning new skills is one thing, but applying them in stressful daily situations is something else, and often, children need support and coaching when they are stressed, when they have forgotten what they have learnt in the therapy sessions. And many children with CD have learnt that some of the problematic behaviour they show is helpful to deal with negative emotions.
So, we need Social Workers, we need Teachers, that can do this in-vivo coaching, you know. In-vivo coaching, is to say, “Hey, when you are in this stressful situation, try to apply the skill you have learnt in the skills training.” So, I think this combination between a skills training and this in-vivo coaching is necessary, and that’s what we name as multimodal, or a comprehensive, intervention approach, and by the way, this is also recommended by the NICE guidelines.
Unfortunately, often, personnel resourcing are lacking, and there’s a high burden in staff. That’s what I have seen when I visited all the institution, and I visited institutions in the Netherlands, in Switzerland, in Germany, and often, this is the case that they are lacking time resources, lacking personnel resources. Politics should also take this seriously into consideration and spend enough money to improve current conditions in welfare institutions or correctional facilities. This is well investigated money, I think.
[00:17:54.020] Mark Tebbs: I’m not sure whether this is, kind of like, outside the scope of the trial, but I was just wondering whether there are any messages to parents or carers.
[00:18:03.090] Professor Christina Stadler: Yes, as a Clinician in my clinic in Basel, I work with parents. I’m responsible for the outpatient clinic, and there we have very young kids, and I would say it’s important to start as early as possible. And, also, for parents, aggressive behaviour can be very, very challenging, especially when children, for example, additionally have callous, unemotional traits, or show very early this aggressive behaviour. That definitely is challenging for parents. And emotional regulation, it’s learnt in the context of others. There’s no child that is born and is able to regulate emotions. So, a child always needs competent, sensitive parents, parents who have the power to set rules, and sometimes the parents need support in doing this in parenting. I would be happy if parents come to us if they need support, and I can see often they need support if a child is too challenging, or if parents have own problems, have stress in life. Then we should start to help them.
[00:19:11.400] Mark Tebbs: Yeah, fascinating. Is there anything from your trial that needs further investigation, and are you planning any follow-up work?
[00:19:18.500] Professor Christina Stadler: Yeah, I would have been interest to follow-up these kids and to have another follow-up assessment that was not planned within this EU study. And what we do now is we investigate whether there’s an impact on the brain of our intervention, so those areas that are affected in girls with reduced emotional regulation capacities are now better. So, that’s what Nora Raschle is doing, and we will submit this paper.
And what we currently are doing, and that’s also an RCT study, is we develop a web-based intervention of START NOW and will investigate whether this self-training might also have an effect. So, that’s what we are – currently are doing, with my team…
[00:20:05.010] Mark Tebbs: Yeah…
[00:20:06.010] Professor Christina Stadler: …in Basel.
[00:20:07.010] Mark Tebbs: …cool, thank you. Look, we’re coming to the end of the podcast, and is there, like, a final take-home message?
[00:20:11.809] Professor Christina Stadler: Yeah, I would say my take-home message is – and especially for those kids with severe aggressive, disruptive behaviour, we have to bring evidence-based care to the settings where the kids live. So, they are not in the clinic with me. They’re there only for diagnostic reason, but they often are in foster care, in institutional care, in correctional facilities. And what I already mentioned, they often are lacking resources, so it’s definitely needed that we bring this evidence-based care to these settings and to take care of the kids.
And also, for the staff or the people who work with these kids, because it’s really challenging for staff, for parents. It’s exhausting to deal with this really disruptive behaviour, with lack of empathy. That there’s a lot of burden in staff and parents, so we have to take care for the whole system.
[00:21:11.530] Mark Tebbs: Thank you so much. It has been a really interesting podcast and really important study. So, for more details on Dr. Christina Stadler, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoyed the podcast, with a rating or review, and do share with friends and colleagues.