For this podcast, we welcome clinical psychologist Eva Kimonis, Professor in the School of Psychology at the University of New South Wales, Sydney, Australia and director of the Parent Child Research Clinic at the same institution.
Eva is also President of the Society for the Scientific Study of Psychopathology, and the first author of the JCPP paper, ‘Facial reactions to emotional films in young children with conduct problems and varying levels of callous-unemotional traits’ (doi.org/10.1111/jcpp.13701). This paper will be the focus of today’s conversation.
To set the scene, Eva first defines what is meant by the term ‘callous-unemotional traits’ and discusses how these generally present, before providing us with a brief overview of her paper.
Eva comments on the methodology used for the study and shares insight into the findings that surprised her from this study, including her finding that the callous-unemotional group showed a high intensity of anger during both the happy film clips and the sad film clips, and what she made of these findings.
Eva then explores why she thinks young children have been missed from these types of studies previously and shares insight into what implications her findings have for developmental models of childhood antisocial behaviour.
Furthermore, Eva comments on how she would like her findings to be translated into practice, how her findings could inform the development of targeted interventions, and what the implications are of her findings for mental health professionals, parents, and teachers.
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Eva R. Kimonis, Ph.D., is a Clinical Psychologist and Associate Professor in the School of Psychology at the University of New South Wales in Sydney, Australia. She received her Master of Science and Doctor of Philosophy degrees in Applied Developmental Psychology from the University of New Orleans, with a specialisation in developmental psychopathology and forensic psychology. A/Prof Kimonis’ program of research focuses on the development, assessment, and treatment of callous-unemotional traits and aggressive behaviour in youth. Her research has been published in top peer-reviewed journals in the fields of clinical, developmental, and forensic psychology, and she has authored several book chapters on antisocial behaviour in youth. She is the recipient of a Fulbright Scholar Grant from the J. William Fulbright Foreign Scholarship Board, and the 2015 Early Career Contributions Award from the Society for the Scientific Study of Psychopathy. A/Prof Kimonis is an experienced provider of parent management training interventions, and specifically Parent-Child Interaction Therapy (PCIT) for young children with disruptive behaviours. She has adapted PCIT to target the unique deficits of antisocial children with callous-unemotional traits. (Image and bio from the University of New South Wales, Sydney, Australia)
[00:00:10.040] Jo Carlowe: Hello, welcome to the In Conversation podcast series, 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 am interviewing clinical psychologist Eva Kimonis, Professor in the School of Psychology at the University of New South Wales Sydney, Australia and director of the Parent Child Research Clinic at the same institution.
Eva is also President of the Society for the Scientific Study of Psychopathology, and the first author of the paper, ‘Facial reactions to emotional films in young children with conduct problems and varying levels of callous-unemotional traits‘, recently published in the Journal of Child Psychology and Psychiatry. This paper will be the focus of today’s conversation. The JCPP is one of the three journals produced by the Association for Child and Adolescent Mental Health. ACAMH also produces JCPP Advances and the CAMH.
If you’re a fan of out in conversation series, please subscribe on your preferred streaming platform. Let us know how we did with the rating or review and do share with friends and colleagues. Eva, welcome. Thank you for joining me. Can you start with an introduction about who you are and what you do.
[00:01:24.050] Professor Eva Kimonis: Happy, too. Thanks for having me, Jo. I’m a professor in the School of Psychology at the University of New South Wales. And my research program here really focuses on understanding why individuals and, in particular, young people develop callous-unemotional traits. We work on how to best measure these traits, and finally, how we can prevent and treat children that have severe disruptive, destructive, and aggressive behaviours, which we refer to collectively as conduct problems.
So, to focus on this interest on treatment in my research, I founded and direct the Parent Child Research Clinic at UNSW, where we really provide cutting edge treatments to young people who have these conduct problems. And we refine how we identify children that are suitable to receive them.
[00:02:12.330] Jo Carlowe: We’re going to look at your paper, ‘Facial reactions to emotional films in young children with conduct problems and varying levels of callous-unemotional traits’, which was recently published in the JCPP. Eva, before we go into the detail, can you define what is meant by callous-unemotional traits. How do these generally present?
[00:02:33.105] Professor Eva Kimonis: Callous-unemotional traits is a term that’s used to describe children who lack empathy, lack remorse after wrongdoing, who aren’t too concerned about their performance at school, or in other important activities, and who experience emotions in a way that is shallow, insincere, and lacking in depth. And these sorts of traits are also seen in adults with psychopathy, in addition to other features like being charming, and manipulative, or having chronic criminality, and reckless, or impulsive behaviours.
But the study of C-traits in children really came about from trying to understand whether these psychopathic traits are also present in childhood. And just like adults who have psychopathy, children that have callous-unemotional traits, tend to show a pattern of disruptive, destructive, and aggressive behaviours that begin early in life, are persistent, and also don’t normalize with some of our best available psychological treatments.
[00:03:32.120] Jo Carlowe: Let’s look at the paper now. Can you start with a brief overview to set the scene for us?
[00:03:38.300] Professor Eva Kimonis: There’s quite substantial evidence that both children with callous-unemotional traits and adults with psychopathic traits show emotional deficits in how they respond to others’ distress. And this can be seen from the level of the brain, to their psychophysiological responding, to their cognition and attention, and more. There’s also evidence that callous-unemotional traits can be reliably and validly measured in children as young as age three.
But relatively few studies have actually focused on this early childhood period or even examined these emotional deficits in young children that have callous-unemotional traits, specifically pre-schoolers. And we also have emerging evidence in older populations that, with callous-unemotional traits, you can see some of their empathy deficits in how they respond with their facial emotional responses during emotional films.
You can see this both using psychophysiological measures, like facial electromyography, as well as more recently developed face processing software. What we really wanted to do in this research is to build on some of that prior research by studying pre-schoolers and seeing whether they show these differences in facial emotional reactions during emotional films, in association with their callous-unemotional traits.
[00:04:55.970] Jo Carlowe: Can you tell us something about the methodology that you use for the study?
[00:05:00.455] Professor Eva Kimonis: What we did is that we recruited 100 preschool children from some of our local area day-cares and also from the UNSW Parent Child Research Clinic to participate in the study. And their parents completed questionnaires that asked about their children’s level of callous-unemotional traits and conduct problems. And we use this information to group the children into three specific groups. We had typically developing children, children with conduct problems alone, so they did not necessarily have elevated callous-unemotional traits, and children that had conduct problems with elevated callous-unemotional traits.
And all of these children watched standardized film clips from the cartoon The Lion King. And these film clips were designed to elicit feelings of happiness, sadness, fear, and anger. And in between each of the emotional clips was a neutral clip, to return their mood to baseline. And we recorded the children, while they watched these films. And we process those recordings using face processing software. And this software, what it does, is it classifies those facial expressions during very brief time periods in terms of the intensity of different emotions experienced by the child or displayed on their faces, which we then combined to figure out whether the child was showing emotion that was congruent with that film clip or incongruent with the film clip that they were watching.
So, as an example, if the child is watching Simba, seeing his father fall to his death, while trying to save Simba, were they showing sadness or fear, which would be considered congruent emotion? So, we actually found that these children with early starting conduct problems, generally showed more incongruence than congruent emotion, while watching sad and happy film clips relative to the typically developing children.
But this difference between groups was largest when we compared the callous-unemotional group against the typically developing group. It was not significantly different between the two conduct problem only groups when we accounted for differences between the children and their sex, age, and ethnicity.
[00:07:08.087] Jo Carlowe: But we will look in more detail at what you found. But did any of the findings surprise you?
[00:07:12.892] Professor Eva Kimonis: I would say there was really two main unexpected findings. So first, our callous-unemotional group showed a high intensity of anger during both the happy film clips and the sad film clips. But also, second, we expected the two conduct problem groups to differ significantly from one another, which they didn’t in our study after we accounted for the sex, age, and ethnicity of the children. And we had several reasons why this could be the case.
Part of it was that our expectation was based on prior studies of older children that use very different types of paradigms, where they were really looking at static images and not these types of mood induction film clips that we used. The second possible reason is that our conduct problem only group still had higher levels of callous-unemotional traits relative to our typically developing children, which could suggest that these emotional deficits exist on a continuum in young children that have severe conduct problems. And we actually found a similar thing when we were looking at emotional attention deficits in pre-schoolers. But this also suggests the possibility that what we used as a cut point to identify callous-unemotional traits, may need some refinement. Maybe it was too high. It was based on another typically developing sample and sort of 1 and 1/2 standard deviations above the mean in that other sample.
But we currently have no established cut scores for identifying elevated levels of callous-unemotional traits in young children. So, we really do need future research to develop those types of cut-offs. And then, I guess, two other possible reasons is that maybe effective empathy is important for the development of general conduct problems in young children. Or maybe these differences emerge later in life or later in development for the two groups of kids with conduct problems.
[00:09:06.770] Jo Carlowe: I want to look at this point about anger. So, the incongruent emotion that children with conduct problems and callous-unemotional traits displayed with the most intensity during both happy and sad film clips was anger. What do you make of that?
[00:09:25.550] Professor Eva Kimonis: I agree it was really interesting and unexpected. And what we came to is that this pattern was possibly due to the attachment related themes of these two film clips, the happy and sad film clips. So, from the happy film clip, we’ve got Simba singing along with his friends and having a great time, so a lot of social affiliated behaviour, which we see as being problematic in kids with callous-unemotional traits.
But also in the sad film clips, you see the significant loss of Simba’s attachment to his father. And this is really interesting because children who have high levels of callous-unemotional traits tend to show disorganized attachment styles, which really involves quite confused or contradictory expressions and behaviours in the context of attachment relationships. And that’s really akin to that incongruent responding that we saw in those attachment related film clips.
And finally, one other possibility is that I’ve done quite a bit of research on a subset of children who have callous-unemotional traits. We refer to them as secondary variants. And this group of secondary variants show really high levels of anger relative to other children. We didn’t have the sample size to break up our groups further into these primary and secondary subtypes. But that is something that we want to do in the future.
[00:10:48.182] Jo Carlowe: Eva, what else would you like to highlight in the paper?
[00:10:51.200] Professor Eva Kimonis: This is really one of the first studies to use this face reader software and technology in young children and with a clinical population, which lends some support to the utility of this technology for this purpose in future research, or, at least, with children ages three and up. So, we think that’s important that being able to look at facial emotional expressions in young children is possible with these types of technologies.
[00:11:18.110] Jo Carlowe: Why do you think young children have been missed from these kinds of studies? Is it because there aren’t the measures and tools? They’re not honed to measure those children, or do people not like to think of young children as having these traits?
[00:11:31.223] Professor Eva Kimonis: Yeah, it’s an excellent question. Because, I think it’s– that’s, in large part, why we are only now really starting to have a lot more research in the early childhood period is because we didn’t really have the tools to measure. We didn’t know that our existing tools could be used reliably and validly in young children. And it wasn’t actually until around 2016 when I published a study that showed that you could reliably and validly assess callous-unemotional traits in children as young as three and that you could measure some of these emotional processing deficits using downwardly extended paradigms from older populations within this age group. So that now puts us in a better position to be able to do more research in early childhood period.
[00:12:14.930] Jo Carlowe: Eva, as your paper state, your findings have implications for developmental models of childhood antisocial behaviour. Can you elaborate on this?
[00:12:24.735] Professor Eva Kimonis: Well, emotional mechanisms have really been put forward as central to why people develop antisocial behaviours and why these behaviours are maintained over time. And we have a lot of evidence from the middle to late childhood period to support this. But there hasn’t really been much investigation into early childhood for the reasons that we talked about just now. And so, this study really lends support to extending this critical mechanism to early childhood, and, in particular, before school age.
[00:12:58.352] Jo Carlowe: In the paper, you state the findings can inform the development of targeted interventions. Can you say more about this. How would you like your findings to be translated into practice?
[00:13:11.130] Professor Eva Kimonis: Children who start showing conduct problems early in life, we know that they show atypical processing of emotion. And atypical emotional processing is also a core feature of adult psychopathy that we see as being evident in young children with callous-unemotional traits. This really suggests to us that a focus on emotions should be a component of interventions for callous, unemotional, and psychopathic traits. And actually, for the past several years, I’ve been developing and testing novel early interventions for children with callous-unemotional traits.
And a core component is on developing the child’s emotional skills. We think that emotion is important. But we’ve also been examining certain parenting behaviours, as they relate to developing emotional skills. So, in particular, we’re interested in parental warmth and emotional connectedness, which has a key role to play in helping children to develop empathic and pro-social behaviour.
And we’re currently working on refining our understanding of these specific parenting behaviours, and how they might contribute to emotional deficits, and how we might target them in these early interventions for children that have callous-unemotional traits. Our next step is to really use this information to refine more comprehensive understanding of emotional deficits and environmental factors that might contribute to children developing conduct problems and callous-unemotional traits and translating this knowledge into more precise and relevant treatment targets in the treatment programs that we’ve developed.
[00:14:45.848] Jo Carlowe: Are you optimistic, that if you start treatment programs very young, that you can change the trajectory?
[00:14:52.310] Professor Eva Kimonis: Absolutely. So, we already have an open trial study and a randomized controlled trial study that we’ve done, tests the targeted early intervention that we developed, finding that the targeted intervention produces quite large changes in children’s conduct problems, but also changes in their callous-unemotional traits. And what’s been really interesting from the randomized controlled trial is that the targeted intervention is doing better at maintaining the changes after treatment ends than standard psychological treatments.
[00:15:25.230] Jo Carlowe: Eva, what are the implications of your findings for mental health professionals, for parents, and teachers?
[00:15:32.903] Professor Eva Kimonis: These findings really continue to highlight how important it is that mental health professionals, and parents, and teachers are able to identify when a young child is struggling to develop empathy or respond appropriately to others’ distress, and being able to identify those problems and refer to treatment, if needed. And we’re currently actually working with schools to help develop this mental health literacy around conduct problems and callous-unemotional traits in teachers, and to teach them how to respond with tailored evidence-based strategies in the classroom.
There’s a lot more work that needs to be done in professional training for mental health professionals and how to work with children and families with conduct problems and callous-unemotional traits. But we’re also in the early stages of developing treatments for this population. So that’s understandable. Generally, I guess, in schools or at home, some of our other research is suggesting that learning and talking about feelings from an early age is important. And, hopefully, altogether, some of this work can address those barriers that families are actually facing, when they’re trying to get help for their young child that has early starting conduct problems.
[00:16:40.710] Jo Carlowe: Eva, are you planning some follow up research, or is there anything else in the pipeline that you’d like to share with us?
[00:16:47.800] Professor Eva Kimonis: Absolutely. So, the paradigm that we use to measure the children’s facial emotional reactions in this study, we think measures one aspect of empathy, which is emotional contagion. That’s the ability to feel what others are feeling. But since that study, we’ve been working on how we can refine our measurement of empathy in young children. And we’ve done this by developing a multidimensional empathy in early childhood scale, which we call the MEEK.
And using the MEEK scale, we found that, after we accounted for other dimensions of empathy in young children, emotional contagion wasn’t significantly associated with callous-unemotional traits. But instead, prosocial behaviour and attention to others distress in young children, were. Now I don’t think this necessarily means that emotional contagion isn’t important. But I think it’s likely that parents wouldn’t be able to pick up on those very subtle changes in their child’s emotional expressions that we were able to with the face processing methodology. But it does suggest to us that we may need to target empathy deficits in these children in a multi-dimensional way that doesn’t just focus on one aspect of empathy. Currently, we’re continuing to work on understanding the early childhood parenting emotional and biological risk factors for conduct problems with callous-unemotional trait.
And our goal is that this more comprehensive understanding of the developmental psychopathology of these subtypes of children with conduct problems will help to improve the treatments and the outcomes of these children and move them off their problematic developmental trajectories. So, we are very much focused on continuing to do translational research in the coming years.
[00:18:34.280] Jo Carlowe: Thank you. Eva, finally, what is your take home message for our listeners?
[00:18:40.650] Professor Eva Kimonis: I think studies like this one really support the importance of continuing to do research into early childhood and into the emotional mechanisms that are thought to contribute to conduct problems in callous-unemotional traits. And there’s other research that is focused on even earlier precursors in the first few weeks of life and has found differences. So, I think there’s a lot more work to be done in the early childhood space.
Because if we hope to be able to reduce the significant societal and personal costs that these children with early starting conduct problems in callous-unemotional traits have, these children who may go on to develop serious delinquency in their adolescence or chronic criminality in their adulthood, it’s really important that we invest in that research in early childhood so we can understand why these problems develop and translate that knowledge into early preventive interventions. So, in some, I think if we know what causes the problem, then we’re one critical step closer to fixing it.
[00:19:41.168] Jo Carlowe: – Absolutely. Eva, thank you ever so much. For more details on Professor Eva Kimonis, 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 enjoy the podcast with a rating or review. And do share with friends and colleagues.