When one size doesn't fit all: temperament-based

Chapter 2

When one size doesn’t fit all: temperament-based parenting interventions Jennifer L. Allen Department of Psychology and Human Development, UCL Institute of Education, University College London, UK Abstract  There is growing recognition of the need for early intervention and prevention work in the field of parenting and child psychopathology. Great strides have been made in the development and broad-scale evaluation of parenting interventions for a variety of childhood mental disorders. However, there are problems with even our current ‘best practice’ parenting interventions including lack of family engagement, failure to achieve clinically significant improvements for a substantial number of families, and difficulty maintaining treatment gains over time. Recently, investigators have drawn on the field of individual differences as a way of answering the question of ‘what works best for whom?’ Researchers are currently exploring how to ‘personalise’ assessment and treatment on the basis of child temperament, an important source of individual differences. This paper will review research and theory demonstrating that the interface between child temperament and parenting has significant implications for the development of child psychopathology and social-emotional skills. This knowledge has informed the selection and assessment of families in early intervention and prevention trials, as well as the nature, content and delivery of parenting interventions. Specifically, temperament-based parenting programmes aim to tailor existing parenting strategies to provide a better ‘fit’ for families on the basis of the child’s temperament profile. Temperament-based parenting interventions are still at an early stage in terms of evaluation, but the evidence to date suggests they are a promising avenue for the treatment of children with a wide range of mental health difficulties. Keywords  Temperament, parenting, early intervention, prevention, child psychopathology Correspondence  Jennifer L. Allen, Department of Psychology and Human Development, UCL Institute of Education, University College London, 20 Bedford Way, London WC1H 0AL, UK; Email: [email protected] doi:10.13056/OP33.e

Key points Clinical practice: Temperament is biologically-based, relatively stable over time, and consists of affective, attentional, sensory and behavioural response systems. Temperament is an important influence on child development, and helps us to better understand the heterogeneity of child psychopathology and social-emotional development. Theoretical mechanisms explaining how temperament and parenting interact to influence the development and maintenance of child psychopathology are varied and complex, and include the identification of direct, bidirectional and transactional relationships over time. Further research and practice development: Temperament may be difficult to alter due to its genetic basis, but theory and research suggests that parenting tailored to ‘fit’ with children’s unique temperament profile may promote selfregulation and reduce emotional and behavioural problems. Temperament-based parenting interventions are still in an early stage in terms of developing an evidence base, but findings so far show promising results for children with a wide range of mental health difficulties.

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Introduction In recent years there has been a much needed shift towards prevention and early intervention for mental 12

health problems in children. This has been driven by a number of factors, including the recognition that mental

ACAMH Occasional Paper 33: Making Parenting Work for Children’s Mental Health © 2015 Association for Child and Adolescent Mental Health. All rights reserved.

ACAMH Occasional Paper 33: Making Parenting Work for Children’s Mental Health disorders often emerge in childhood and increase the risk for later psychopathology including adult anxiety, depression, eating disorders and substance abuse (Kessler, Berglund, Demler, Jin, & Walters 2005; Kim-Cohen et al., 2003). Childhood mental disorders are associated with a range of poor long-term outcomes including compromised physical health and impaired functioning in interpersonal relationships, educational and work settings (Maughan & Kim-Cohen, 2005). Prevention and early intervention programmes therefore offer great potential for cost-effectiveness given the substantial financial burden childhood mental disorders place on health, social, educational, and in the case of antisocial behaviour, legal services (Scott, Knapp, Henderson, & Maughan, 2001; Snell et al., 2013). Programmes are often chiefly or solely directed at parents, due to young children’s understandable reliance on their parents for assistance in managing their emotions and behaviour. Furthermore, both child behaviour and parenting practices are likely to exhibit greater malleability in early rather than later childhood. Ideally, support should be provided before difficulties produce increasing distress and impairment, placing pressure on family relationships and resulting in dysfunctional patterns of parent–child interaction becoming entrenched (Dadds et al., 1997). Great strides have been made in the development and evaluation of parenting interventions for a range of childhood disorders. However, outcomes for our ‘best practice’ evidence-based family interventions suggest there remains substantial room for improvement. For example, meta-analytic research has indicated that family-based cognitive-behavioural therapy (CBT) for childhood anxiety disorders is associated with a mean effect size of only 0.38 (range from 0.29 - 0.51) (James, Soler, & Weatherall, 2005). Similarly, parent training (PT) interventions for childhood conduct problems have been associated with a mean effect size of 0.47 (range from 1.68–0.06) (McCart, Priester, Davies, & Azen, 2006). Evaluations reveal that even high quality evidence-based family interventions delivered under optimal conditions fail to produce clinically significant improvements for a quarter to one-third of families (James et al., 2005; Scott & Dadds, 2009). For those children who do experience an immediate benefit, outcomes vary in the extent to which improvements generalize beyond the family setting to other domains (e.g., academic, peer, leisure), and some children will experience a recurrence of difficulties in the longer term (McMahon, 2008). Premature termination of therapy is a major problem for the treatment of children and adolescents, with some studies revealing dropout rates as high as 40–60% of families (Kazdin, 1997). Thus there are large numbers of children and families who are not engaged in treatment and for whom it does not produce a recognizable long-term benefit. Different approaches have been taken to address the issues of family disengagement and treatment failure,

including improvement of the reach, flexibility and quality of care provided (e.g., Sanders, 2012; Webster-Stratton, 2011). These methods have included investigating treatment provision in a range of clinical and community settings, implementation, therapist training and supervision, different formats (e.g., individual or group family intervention) and modes of delivery (e.g., bibliotherapy, video-guided and internet-based therapies). Evidence-based interventions have also incorporated strategies targeting factors that may have direct or indirect effects on parenting including parental psychopathology (e.g., anxiety, depression, substance use), maladaptive cognitions (e.g., hostile attributions, anxious cognitions), parent conflict, social disadvantage and social isolation (e.g., Hudson et al., 2014; Leijten et al., 2014; Sanders et al., 2004). While research in this area to date has primarily attempted to improve treatment outcomes by targeting family risk factors, there is increasing interest in how our understanding of individual child characteristics can inform early intervention and prevention work. More specifically, clinical researchers have looked to theory and research in the field of child temperament for guidance on how to provide individualized assessment and treatment for children and families.

Child temperament Temperament can be viewed as the basic nature of a person, forming the ‘building blocks’ or core underlying individual differences in personality. A popular contemporary definition refers to temperament as constitutionally-based individual differences in reactivity and self-regulation (Rothbart & Bates, 2006). Reactivity refers to responses to internal and external environments, involving affective, attentional, motor and sensory response systems. Research on child temperament has focused on many different indicators of positive and negative affect including anger, sadness, fear (inhibition, withdrawal), pleasure, positive anticipation and approach (Kiff, Lengua, & Zalewski, 2011). Self-regulation refers to the goal-directed regulation of reactive, behavioural, attentive and affective processes which are viewed as automatic and involuntary. In contrast, regulatory processes are intentional, planned and voluntary, allowing individuals to modulate their reactivity in an anticipatory or correctional manner in order to adapt to their environment. Reactivity is evident from infancy onwards, whereas effortful, regulatory aspects of temperament emerge over time as children mature physically and develop important cognitive and social skills that influence the expression of their unique temperamental characteristics. Temperament-based interventions often incorporate parenting strategies aimed at supporting and further developing children’s regulatory capacities, discussed in greater detail later on. Temperament has a genetic basis, with heritability estimates for broad temperament dimensions ranging 13

Allen: When one size doesn’t fit all: temperament-based parenting interventions from .5 to .8 (Kiff et al., 2011). It is also relatively stable across time and situations, with estimates ranging from .3 to .8 depending on the trait dimension and the developmental period. In general, stability is modest during the infant and toddler years, followed by a large increase at around three years of age, then demonstrating moderate stability throughout childhood and adolescence (Nigg, 2006). However, while temperament has a biological basis and is relatively enduring, it is also widely recognized that it is influenced by experience and maturation (Rothbart & Rueda, 2005). For example, temperament traits (e.g., activity level, sensation-seeking) may be more salient or alter in their expression at different points in development. Behavioural indicators of child temperament-based behaviours may also only be observable in relevant contexts. For example, a child may appear confident and sociable when interacting with close family and friends, but shy and inhibited when interacting with unfamiliar peers. Temperament can therefore be thought of as referring to predisposing individual characteristics that can change over time as the child develops, and which can be expressed in different ways in response to the environment (Nigg, 2006). Rather than representing fixed, immutable qualities, temperament may provide ‘reaction ranges’ or expectable variation ranges for developmental pathways (Wachs, 2006). Temperament shapes child development, and therefore the development of psychopathology, but it is also shaped by the environment. This is an important point for clinicians, researchers and policy makers, as it indicates that there is scope for interventions to reduce psychopathology in children at-risk due to their temperamental profile. Temperament is typically included as a risk factor in theoretical models outlining the development of child psychopathology and has consistently been identified as an important contributor to children’s social and emotional development. The ability to effectively regulate emotion, attention and motivation (termed ‘effortful control’) is associated with improved child adjustment, empathy, social competence and self-esteem (Eisenberg, Vaughan, & Hofer, 2009). Negative emotionality and low effortful control are associated with internalizing and externalizing problems (Sanson, Hemphill, Yagmurlu, & McClowry, 2011). Fearfulness or behavioural inhibition is a risk factor for anxiety disorders (Kagan, 1989). High levels of activity and approach predict externalizing problems (Frick & Morris, 2004; Nigg, 2006). Impulsivity is associated with externalizing problems and poor social skills (Sanson et al., 2011). Low levels of approach, positive emotionality and effortful control are associated with depression (Nigg, 2006), while irritability is related to internalizing problems and reduced social competence (Eisenberg et al., 2009; Stringaris, 2011). There are many different possible explanations for the links between temperament, child psychopathology

and social-emotional development. Child outcomes may represent a direct linear effect of temperament, such as callous–unemotional (CU) traits predicting more severe antisocial behaviour (see Hawes, this series) or the additive effects of different temperament traits, such as the combination of high negative emotionality and impulsivity increasing the likelihood of aggressive behaviour (Sanson et al., 2011). Temperament also plays a strong role in social interactions and social functioning. For example, a child who is high in effortful control can use his ability to delay gratification to behave in a socially competent and prosocial manner (e.g., sharing toys, taking turns). Traits may also interact with one another to produce certain outcomes. For example, an inhibited child with high levels of effortful control may be able to re-focus her attention away from negative social cues in her environment to reduce her anxiety levels (e.g., redirecting her attention from someone who appears bored to someone who is smiling while giving a speech). In the following section, different mechanisms and models that have been proposed to explain how the interplay between temperament and parenting influences child psychopathology and social-emotional development are explored.

Child temperament and parenting Shiner and Caspi (2003) described a number of different mechanisms that explain how temperament shapes, and is shaped by the context in which children develop. These mechanisms contribute to the elaboration of children’s inherited temperamental characteristics into cognitive and affective representations that are quickly and frequently activated through repeated reinforcement during child-environment interactions over time. The first proposed mechanism relates to temperamental influences on how children interpret and respond to their environment. For example, a child who is very headstrong may interpret requests from her parents as hostile impositions upon her autonomy, and react with defiance. Temperament also contributes to children’s evaluations of themselves relative to others, such as a shy child wrongly perceiving himself to be less competent than his siblings or peers. Children may also select and structure their environments to produce a ‘good fit’ with their temperament (Chess & Thomas, 1991). For example, an active, exuberant child may seek out the attention of a parent or sibling who also enjoys roughand-tumble play. Temperament also influences child development through its influence on learning processes, including operant and classical conditioning. For example, Kochanska (1991; 1997) demonstrated that gentle parental discipline was effective in promoting the development of conscience in fearful toddlers, whereas high levels of power-assertive parental discipline resulted in a less optimal outcome. Another mechanism describes 14

ACAMH Occasional Paper 33: Making Parenting Work for Children’s Mental Health

Child temperament and parenting: implications for prevention and early intervention

how temperament may shape parental responses. For example, sociable children may elicit positive responses from their parents, whereas children who are irritable and headstrong may elicit harsh responses. It is important to note that temperament influences the expectations, as well as the behaviour of others. For example, a parent of an inhibited child may avoid taking him to new social activities in the belief that he will be unable to cope. Thus certain temperamental traits may elicit parenting that, while intended to reduce child negative affect, may actually serve to compound the child’s difficulties. Conversely, parents may respond in an encouraging manner to behaviours reflective of temperamental characteristics such as positive affect, effortful control and agreeableness which in turn elicit parenting (e.g., parental warmth and involvement) known to promote healthy child development. In bidirectional or transactional models, child development is viewed as an outcome of reciprocal relations between child characteristics and the environment, with child temperament and parenting expected to mutually influence each other over time (Kiff et al., 2011). Temperament may also serve as a moderator of the relationship between parenting and child adjustment (Rothbart & Bates, 2006). That is, the degree of influence of parenting and even the direction of effect may vary depending on the child’s temperamental characteristics, rather than exerting a uniform effect across all children. For example, Thomas and Chess (1977) proposed that child adjustment is promoted when their temperament is a ‘good fit’ for the demands, expectations and opportunities of their environment. A more recent model, the differential susceptibility hypothesis, proposes that temperament, particularly emotional reactivity, increases children’s responsiveness to parenting practices associated with both positive and negative outcomes (Belsky & Pluess, 2009). This differs from a diathesis-stress model (e.g., Monroe & Simons, 1991) which presumes that a child may be more vulnerable (or resilient) to poor parenting due to his or her temperament, but does not make any predictions about how this same child would respond to ‘positive parenting’. Finally, the vantage sensitivity model refers to the general proclivity of a child to benefit from the well-being and competence-promoting features of parenting (Pluess & Belsky, 2013). Vantage sensitivity differs from the diathesis-stress framework focus on the positive consequence of not succumbing to an adverse experience, and from differential susceptibility in that it predicts that some children may ‘shine’ when raised in a warm, loving family environment but remain relatively unaffected by negative parenting practices. In general, there is empirical support for all of these aforementioned models in explaining the nature of the relationship between child temperament, parenting and psychopathology (see Kiff et al., 2011; Pluess & Belsky, 2013, for reviews).

Theory and research on child temperament and parenting has clear implications for the prevention and early intervention work. First of all, this knowledge base reveals that certain temperament traits or combinations of traits and family risk factors increase the risk for later psychopathology, allowing children and families who are most in need of support to be identified. The plethora of available measures to assess child temperament can assist in identifying at-risk children, and in case formulation and treatment planning. In general, research on child temperament has tended to rely heavily on parent-report questionnaires due to its focus on infancy and early childhood. However, many research groups have different questionnaires to assess temperament during different developmental periods (e.g., infancy, toddlerhood, early and middle childhood, adolescence), and may also feature child and/or teacher-report versions, such as the Carey Temperament Scales (e.g., Carey & McDevitt, 1978) and the Child Behavior Questionnaire (e.g., Rothbart, Ahadi, Hershey, & Fisher, 2001). Other researchers (e.g., Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005) have used a combination of parent-report questionnaires and observational methods to select children at risk due to their temperamental status for inclusion in an evaluation of a parenting intervention. Child temperament research has also been used to inform the content of parenting interventions. Evidence-based parenting interventions typically incorporate information about temperament and its influence on child behaviour and adjustment (e.g., ‘Cool Little Kids’; Rapee, Lau, & Kennedy, 2010). For example, open acknowledgement that parents of children with high levels of emotionality, impulsivity, and low effortful control are in need of extra support to avoid the negative responses that these traits can elicit may also promote better engagement through avoidance of ‘parent-blaming’. Information can also be provided to address parent expectations and attributions about their child’s temperament-related behaviours. For example, parent hostile attributions are a well-documented correlate of childhood conduct problems and are associated with poor outcomes to parent training interventions (e.g., Miller & Prinz, 1990). Parents may view problem behaviours as unchangeable, deliberate attempts to upset or annoy them, a sign of serious mental health problems, inherited from other family members (e.g., a violent ex-partner), or a ‘punishment’ that the parent somehow deserves (Scott & Dadds, 2009). On the other hand, parents may dismiss ‘good’ behaviour as transient, due to external factors, and situationally specific. It is difficult for parents to show warmth towards their child when they behave well and to discipline calmly when these ‘hot’ cognitions are present. Psycho-education can 15

Allen: When one size doesn’t fit all: temperament-based parenting interventions increase parents’ understanding and recognition that certain situations are likely to be challenging for their child due to their innate temperamental characteristics, while emphasizing that with parent and other environmental support it is possible for their child to overcome these challenges (McClowry, 2003). Finally, an exciting and promising approach still in the early days of exploration is specifically tailoring parenting intervention strategies for children with certain temperamental traits or profiles. This may involve either modifying existing parenting strategies for children of different temperament types, or developing new strategies targeting malleable risk factors associated with temperament. For example, the work of Kochanska (1991, 1997) suggests that parental discipline needs to be modified for children with fearful versus fearless temperaments, while others have suggested that eye gaze deficits during parent–child emotional interactions is a potential treatment target for antisocial children with CU traits (Dadds, Allen et al., 2014). The use of individualized treatment strategies may help foster parent understanding, sensitivity and responsiveness during interactions with their child, thereby improving the parent–child relationship. Thus temperament-based interventions have great potential for enhancing family engagement and outcomes given their acknowledgement of the child’s unique temperament and the accompanying strengths and challenges these characteristics provide. In the following section, the conceptual and empirical basis for parenting interventions informed by child temperament is reviewed.

adulthood. On the basis of parent descriptions of child behaviour, they identified nine dimensions of child temperament and proposed three main typologies featuring different combinations of these traits: ‘easy’, ‘difficult’ and ‘slow to warm up’. Difficult temperament comprises intense negative mood, high withdrawal in response to new situations, slow adaptation to change and irregular biological functioning (eating and sleeping patterns). Infants with an ‘easy’ temperament have regular biological functioning, readily adapt to change, show positive approach behaviours in new situations, and display mild or moderate levels of positive affect. Infants who are ‘slow to warm up’ tend to show initial withdrawal from new people or situations, are slow to adapt to change and have low activity levels. Thomas, Chess & Birch (1968) found that approximately 65% of infants could be classified as easy, difficult, or slow to warm up, with the remainder showing different combinations of traits from these three categories. Infants in the ‘difficult’ category were at greatest risk for later psychopathology, with 71% experiencing significant behaviour problems (Chess & Thomas, 1986). However, factor analytic research using questionnaires designed to assess the trait dimensions identified by Thomas and Chess (e.g., Carey and McDevitt, 1978) has shown little support for a nine dimensional structure; instead there appears to be three or four dimensions including activity, persistence/ attention, irritability and social inhibition (e.g., Presley & Martin, 1994). The typology proposed by Thomas and Chess (1977) is controversial due to the value-laden terminology. Parents who perceive their child positively may find the term ‘difficult’ to be derogatory, resulting in disengagement (McClowry & Collins, 2012). Furthermore, although many parents find ‘difficult’ children hard to manage, others may not share this experience if they are better equipped to prevent or manage problem behaviours. While this term is still in common use in research and practitioner circles, some have chosen to re-label this category. For example, in her temperament-based parenting programme Sandee McClowry (2003) refers to such children as ‘high maintenance’. There is also the reality that temperamental characteristics that are related to poor functioning in one context may be advantageous in another, and vice versa. For example, persistence is generally regarded as a ‘positive’ temperament trait; but it may come at the expense of the flexibility needed to effectively manage certain challenging situations or life circumstances. The interpretation of what constitutes an ‘easy’, ‘difficult’ or ‘slow to warm up’ temperament and the degree to which this temperament type is viewed as problematic is also likely to vary depending on parental and cultural views, attitudes and practices. Thomas and Chess (1977) also proposed a framework outlining how the relationship between temperament and the environment relates to child adjustment. The term goodness of fit is used to refer to an optimal

Child temperament, parenting and ‘goodness of fit’ Stella Chess and Alexander Thomas (1986) were a couple and psychiatrist team who laid the early foundations for the conceptualisation, measurement and clinical application of temperament research to parenting. They proposed that children are born with different behaviour styles which influence how they interact with their environment, based on their own clinical observations and personal experience of parenthood. The emphasis on children as active agents in shaping their environment through their inherited, internal characteristics represented a major shift from predominant psychodynamic and social learning theory perspectives which primarily attributed the development of child psychopathology to external influences. Thomas and Chess felt that this did not portray a complete or accurate view of child development and were concerned that the emphasis on external influences had resulted in ‘parent-blaming’ (particularly mothers). By 1956, Chess and Thomas had begun the New York Longitudinal Study (NYLS; e.g., Thomas et al., 1963), where children from 85 middle-class families were followed up at regular intervals from infancy until early 16

ACAMH Occasional Paper 33: Making Parenting Work for Children’s Mental Health match between a child’s temperamental characteristics and the expectations, demands and opportunities of their environment. In contrast, poorness of fit refers to a poor match between the child’s temperament and their environment. Within this framework, goodness of fit promotes child social-emotional competence and psychological adjustment; poorness of fit leads to behaviour problems and poor adjustment. This model has positive implications in that it predicts that psychopathology can be reduced or prevented by supporting the emergence of positive capacities or by altering the environmental conditions. Sensitive parent–child interactions require parents to adapt their behaviour and expectations to provide their child with a ‘good fit’ based on their unique temperament, and parents of children with challenging temperaments may need help understanding and/or managing behaviour. This model has an intuitive appeal and encourages parents, researchers and practitioners to understand children’s temperamental characteristics and behaviour within the context of their environment. In the following section, INSIGHTS into Children’s Temperament (McClowry, 2003), a parenting intervention informed by the ‘goodness of fit’ model is described and the evidence for its effectiveness is reviewed.

failure to set limits (McClowry & Collins, 2012). Rather, the aim is to help parents understand the type of positive parenting (e.g., praise, warmth, spending time together) and discipline strategies that are likely to be optimal given the child’s temperamental characteristics. The second component, ‘Gaining Compliance’, focuses on identifying and implementing strategies matched to specific child temperament profiles. A number of behaviour management strategies are introduced, including positive parenting strategies and discipline strategies. Positive parenting strategies include parental warmth and affection, praise, attention (e.g., spending time together), behaviour contracts (goal setting, responsibilities and rewards) and monitoring. These strategies are viewed as essential for preventing challenging behaviours and strengthening the parent–child relationship, which in turn promotes communication and child compliance. In contrast, discipline strategies are implemented once the challenging behaviour has already occurred and are aimed at discouraging the child from repeating the undesirable behaviour in future. In the INSIGHTS programme, the use of consistent, non-physical discipline is advocated, with endorsed strategies including time out, loss of privileges and natural consequences when appropriate. Parents are encouraged to consider the child’s temperament, developmental level, the severity of the behaviour and the situational context when selecting and implementing strategies. For example, a child high in withdrawal may do exactly that if a parent is too intense and instead a gentle disciplinary response is likely to be more effective, whereas children high in approach may require firmer discipline. Likewise, children differ in their preference for the type and intensity of rewards, including parental expressions of warmth and affection. The third component of INSIGHTS, ‘Fostering Self-regulation’ or ‘Giving Control’, aims to promote children’s ability to self-regulate their emotions, attention and behaviour. Parents and teachers identify situations likely to be challenging due to child’s temperament, and provide ‘goodness of fit’ through the use of scaffolding and stretching. Scaffolding involves assessing the situation in relation to the child’s temperament and helping the child to manage it by providing the appropriate type and level of support. If the situation is likely to be overwhelming for the child, the challenge is removed or the demands it places on the child are reduced. However, if the child is perceived as being able to manage the situation with support, strategies are applied to gently ‘stretch’ the child’s emotional, attentional, or behavioural capabilities (McClowry & Collins, 2012). In this manner, children can gradually learn to utilise these strategies to enhance their self-regulatory capacities, allowing them to become more competent when faced with situations that are challenging due to their temperamental characteristics.

INSIGHTS into Children’s Temperament INSIGHTS into Children’s Temperament is a universal socio-emotional intervention programme developed by Sandee McClowry (McClowry, 2003). Although INSIGHTS was originally intended as a parenting intervention, interviews conducted following classroom observations during initial development work indicated that teachers were enthusiastic about the programme and felt that their involvement and a classroom component would be beneficial. The parent, teacher and child programmes are manualized and include videotaped vignettes, session handouts, role plays and group discussion. The parent and teacher programmes involve 10 two-hour weekly workshops, consisting of three components: i) ‘The 3 Rs of Child Management: Recognize, Reframe, Respond’, ii) ‘Gaining Compliance’, and iii) ‘Fostering Self-regulation’. The first component places emphasis on recognizing children’s unique qualities as expressions of their temperament. Recognition is the first step towards reducing misattributions of intentionality to children’s behaviour by understanding that challenging child behaviours are temperament-driven reactions to situations, rather than deliberate attempts to frustrate others. The second step of this component involves reframing perceptions to help parents understand that every child’s temperament has strengths and areas of concern. The third step, respond, acknowledges that while temperament is not easily amenable to change, parent and teacher responses can positively influence child behaviour. Importantly, acceptance of a child’s temperament does not imply permissiveness or a 17

Allen: When one size doesn’t fit all: temperament-based parenting interventions The child version of the programme consists of ten 45-minute classroom weekly sessions delivered in parallel with the teacher and parent programmes. These sessions focus on increasing children’s understanding of their own and others’ temperament and problem-solving skills. Children are introduced to four puppets who each represent common temperament typologies: Coretta the Cautious (high withdrawal and negative reactivity), Hilary the Hard Worker (high task persistence, low activity and negative reactivity levels), Gregory the Grumpy (high negative reactivity and activity levels, low task persistence) and Freddy the Friendly (high approach, low reactivity). The children view videotaped vignettes that demonstrate each puppet’s reactions to a variety of situations and the type of situations they find easy and difficult. Children interact with the puppets and their peers to problem-solve daily dilemmas using three separate steps: i) identifying problems (‘Stop: Recognize a Dilemma’), ii) generating solutions, selecting and developing a plan (‘Caution: Think and Plan’), and iii) implementing and evaluating the selected strategy (‘Go: Try it out’). Worksheets, books and vocabulary flashcards are used to illustrate different principles and reinforce session content. To date, INSIGHTS has been evaluated in two randomized controlled trials (RCTs), with a further group-randomized trial focusing on student behaviour and teacher practices in elementary schools currently underway. In the first prevention trial (McClowry, Snow, & Tamis-LeMonda, 2005), INSIGHTS consisted of parallel parent and teacher programmes conducted over ten weeks. During this same period, children completed the classroom component of the programme. Schools were randomised to INSIGHTS (four schools) or an attention control condition which consisted of a ‘Read Aloud’ afterschool programme (two schools). Participants were 148 children aged 5 to 9  years (55% boys) attending inner-city primary schools, their parents and 46 teachers. Children’s ethnicity was primarily Black (89%), Hispanic non-Black or racially mixed (11%), with the majority of children qualifying for free lunch programmes and living in single parent homes. Forty-two children (28%) met diagnostic criteria for a disruptive behaviour disorder (attention deficit/hyperactivity disorder, oppositional defiant and/or conduct disorder), with no significant differences in the proportion of diagnosed children in the INSIGHTS and Read Aloud conditions. INSIGHTS was more effective than Read Aloud in reducing children’s behaviour problems at home for the diagnosed and non-diagnosed children, but demonstrated greater efficacy for children with a disruptive behaviour disorder than children with subclinical or normal levels of behaviour problems. Programme benefits extended to the classroom, with boys who received INSIGHTS showing significantly greater reductions in teacher-reported attentional difficulties and aggression than boys in the Real Aloud condition

(McClowry, Snow, Tamis-LeMonda, & Rodriguez, 2010). Teachers also perceived boys in INSIGHTS as more competent and reported greater confidence in their ability to provide effective discipline and handle disruptive and inattentive behaviours. However, there were no differences between the two conditions for girls in the classroom setting. The second trial compared a collaborative model to parallel teacher/parent sessions, based on feedback from parents and teachers who participated in the earlier trial (O’Connor, Rodriguez, Cappella, Morris, & McClowry, 2012). In this model, half of the parent and teacher workshops were held together and half were held separately. During the combined workshops, the focus was on facilitating communication and collaboration between parents and teachers. The content of the parent/ teacher workshops was expanded to include information and strategies to facilitate this process, such as listening, assertiveness, recognition of others, cooperation, problem solving, conflict resolution and anger management. These competencies were also emphasized in the classroom component to foster social skills in children. This study included 202 parents and children from 11 inner-city elementary schools. Once again, participants were predominantly Black (54%), with the remainder Hispanic non-Black (44%) or racially mixed (2%). Children in both conditions showed significant reductions in behaviour problems over time. However, following the intervention children in the collaborative model showed a more rapid decrease in disruptive behaviour than those allocated to the parallel model. Temperament typology had an influence on intervention outcomes, with ‘high maintenance’ children in the collaborative condition showing greater benefits in terms of reductions in disruptive behaviour than children of the same temperament type who received the parallel model. Follow-up analyses indicated that these benefits for ‘high maintenance’ children appeared to be mediated through greater improvements in the self-efficacy of parents who received the programme in the collaborative format compared to parents where workshop content was delivered separately for parents and teachers.

Parenting and behavioural inhibition Behavioural inhibition (BI) refers to a temperamental style characterised by heightened motor and emotional reactivity to novelty (Kagan, 1989). BI children are timid, wary and avoidant of unfamiliar people, objects and situations. Unlike other models of child temperament, Kagan focuses on one dimension and views behaviourally inhibited and uninhibited (BIU) children as categorically distinct from one another due to different biological factors (Kagan & Snidman, 2004). BI children are viewed as having inherited a particular neuroanatomy and/or neurochemistry, creating a hyperexcitable amygdala which results in a susceptibility to overreact to 18

ACAMH Occasional Paper 33: Making Parenting Work for Children’s Mental Health unexpected or novel events (Schwartz, 2012). Approximately 15–20% of infants in the general population can be classified as BI, with 50–80% of the variance in this trait typology accounted for by genetic influences (Dilalla et al. 1994). BI is associated with social reticence, not engaging in or avoiding peer interaction, lack of assertiveness, peer rejection, fewer friends, anxiety and loneliness (see Eisenberg et al., 2009). It is important to note that while not all infants or young children classified as BI go on to develop an anxiety disorder, stability of BI across childhood and adolescence predicts the later onset of anxiety, in particular Social Anxiety Disorder (Lahat, Hong, & Fox, 2011). Maternal overinvolvement, negative or critical parenting and ambivalent attachment are associated with BI in young children, and maternal overinvolvement predicts increases in BI over time (Hudson, Dodd, & Bovopolous, 2011a, 2011b). Unsurprisingly, children classified as BI are also more likely to have a parent who is anxious (Biederman et al., 2001). Theories outlining the role of parent–child interaction and temperament in the development of anxiety argue for both reciprocal and interactive effects. However, there is some evidence suggesting that children’s anxious behaviours may elicit overprotective parenting (Rapee, Schniering & Hudson, 2009).

parent workbook containing information and homework activities to consolidate material presented in-session. A follow-up phone call is conducted one month following programme completion to motivate parents to continue working towards their long-term goals and problem-solve any difficulties they may be experiencing. Cool Little Kids is typical of CBT programmes for childhood anxiety disorders, and therefore differs from INSIGHTS in that it is not a ‘temperament-based’ programme in the truest sense. However, this is reflective of the fact that the programme is specifically designed for anxious children and the relationship between temperamental vulnerability and anxiety is often viewed as lying on a continuum, with BI at one end and a full-fledged anxiety disorder at the other. In contrast, INSIGHTS is a universal prevention programme intended to be applied to children with widely differing temperament profiles that potentially place them at risk for a range of emotional and behavioural difficulties. Cool Little Kids has been evaluated in two randomized controlled trials to date with preschool-aged children from predominantly white, middle-class families. Although it was initially conceptualized as a preventive intervention, the majority of children (90%) classified as BI following the screening process met criteria for one or more anxiety disorders prior to the intervention. In a later trial which included children selected on the basis of combined risk including BI status and a parent with an anxiety disorder (Kennedy et al., 2009), all children met criteria for an anxiety disorder at baseline. Thus, these trials do not fall under the traditional definition of ‘preventive intervention’ (e.g., Mrazek & Haggerty, 1994) and may be viewed by some as more accurately described as early intervention (Allen, Creswell, & Murray, 2013). In the first trial, Rapee et al. (2005) randomly allocated 146 families to the intervention condition or a monitoring condition for one year, during which time families did not receive any treatment. At the 12-month follow-up, rates of anxiety diagnoses were significantly (albeit slightly) reduced for preschool-aged children whose parents received the intervention in comparison to the monitoring condition (50% vs. 63%). Children whose parents completed the intervention also showed significantly reduced frequency of anxiety diagnoses and anxiety symptoms 2 and 3 years following the intervention compared to children in the monitoring group (Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2010). However, follow-up assessments revealed that reductions in BI were apparent for both groups. Therefore the positive outcomes of intervention did not appear to be mediated through the hypothesized mechanism of change, reductions in BI. Rapee (2013) recently reported the findings of an 11-year follow-up conducted with 70% of the original families from this RCT, when children were around 15 years old. Girls whose parents received the early intervention programme met criteria for fewer internalising disorders, lower levels of maternally

‘Cool Little Kids’ Rapee and colleagues (e.g., Kennedy, Rapee, & Edwards, 2009; Rapee, et al., 2005) selected children to participate in a prevention/early intervention CBT-based parenting programme for child anxiety named Cool Little Kids on the basis of high levels of BI, due to its status as a risk factor for anxiety in children (Rapee et al., 2010). This type of approach is termed selective prevention, and it involves identifying children at risk for a mental disorder due to the presence of psychological, biological or environmental risk factors. Preschool children were screened on the basis of maternal report of BI, followed by laboratory observation of child behaviour during basic medical procedures (e.g., chest electrodes, blood pressure cuff), singing a song into a microphone and interactions with a same-aged peer, adult strangers and novel toys. Cool Little Kids is a six-session (90 minutes each) parent-focused intervention which includes psycho-education (including the nature of BI, its status as a risk factor for anxiety and relationship with parenting), parent management skills, cognitive restructuring, graded exposure and relapse prevention. Parents apply strategies such as cognitive restructuring and graded exposure to their own anxieties to provide a model of ‘bravery’ and to gain insight into their child’s experience of the strategies. Families are encouraged to continue to use these strategies following the completion of the programme. Cool Little Kids is delivered by clinical psychologists in a group format, with a maximum of six parents in attendance. It includes a therapist manual and 19

Allen: When one size doesn’t fit all: temperament-based parenting interventions reported anxiety symptoms and self-reported life interference than girls allocated to the monitoring group, while few differences were present for boys. This is an extremely impressive result for a very long-term follow-up, especially when considering the relatively brief, group format of the intervention. The following RCT (Kennedy et al., 2009) selected preschool children (3 to 4 years) on the basis of a combination of two risk factors: high levels of BI and a parent with an anxiety disorder. The rationale for the changed selection criteria was that this combined risk would increase the likelihood that support was provided to children likely to show greater stability in BI over time. Unsurprisingly, children participating in this RCT had significantly higher levels of inhibition than in the first trial. The intervention was extended to include an additional two sessions, chiefly focusing on parent anxiety management given the altered selection criteria. Seventy-one families were randomly allocated to Cool Little Kids or placed on a six month waitlist. Children whose parents attended Cool Little Kids were significantly more likely to be free of their anxiety diagnosis following treatment compared to those in the waitlist condition (46.7% vs. 6.7%). Children in the intervention condition also showed significant reductions in parent-reported symptoms of anxiety and associated impairment. In contrast to the previous trial, there were significant reductions in BI for the intervention group relative to waitlist controls, on the basis of both parent report and laboratory assessment of child behaviour (e.g., increased speech and interaction with strangers). The findings of this study provide grounds for optimism in suggesting that a brief parent-focused intervention can alter the trajectory of anxiety for children known to be at high-risk for later anxiety disorders. Rapee, Bayer and colleagues (Bayer et al., 2011) are currently conducting a community intervention trial which involves the universal screening of 500 children attending preschool services in Australia on the basis of parent-report of BI. The six-session version of Cool Little Kids plus four-week post-intervention booster session will be delivered to groups of parents (~12 individuals) by early childhood professionals who will receive training and supervision in CBT by accredited trainers. Parent groups will be run at the participating preschools or other local community venues (e.g., maternal and child health services). Parents who receive the intervention will be compared to a ‘care as usual’ monitoring group. This population-level community-based prevention trial will include an economic cost-benefit

analysis of longer-term outcomes for intervention versus control children from a broader societal perspective. Little is known about the cost-effectiveness of preventive interventions for child anxiety, or their feasibility in community settings delivered by community-based practitioners, therefore this work represents an important step for the field.

Conclusions and future directions There is substantial evidence showing that certain temperament traits and temperament profiles confer greater risk for child psychopathology. These negative consequences of temperamental risk appear to be magnified when additional risk factors are present, including parent psychopathology and dysfunctional parenting practices. Temperament-based prevention and early intervention programmes have demonstrated positive outcomes for children with a range of mental health problems and their families. Interestingly, findings from an evaluation of the INSIGHTS programme suggested that benefits may be enhanced by facilitating communication and collaboration between parents and teachers (O’Connor et al., 2012). The impressive very long-term outcomes following a relatively brief group parenting intervention for child anxiety indicates that selective prevention targeting children at-risk based on their temperament characteristics is a very promising approach (Rapee, 2013). To date this strategy has been limited to inhibited children, but it clearly has the potential for application to children with a range of different temperament profiles. Research into relationships between temperament, parenting and child psychopathology highlight the importance of understanding children’s temperamental characteristics, along with the challenges these unique characteristics may pose for parents. The evidence base for temperament-based parenting interventions is still in the early stages of development. However, initial findings suggest that identifying children in need of support due to temperamental risk and the development and integration of strategies tailored towards children’s unique temperament into existing treatments represents a fruitful direction for parenting interventions.

Acknowledgements This contribution was specially invited for this publication. The author has declared that she has no competing or potential conflict of interest in relation to this article.

References Allen, J. L., Creswell, C., & Murray, L. (2013). Prevention of anxiety disorders. In P. Graham & S. Reynolds (Eds.), Cognitive Behaviour Therapy for Children and Families (3rd ed., pp. 323–336). Cambridge: Cambridge University Press.

Bayer, J. K., Rapee, R.M., Hiscock, H., Ukoumunne, O.C., Mihalopoulos, C., Clifford, S., & Wake, M. (2011).The Cool Little Kids randomised controlled trial: Population-level early prevention for anxiety disorders. BMC Public Health, 11(1), 11.

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ACAMH Occasional Paper 33: Making Parenting Work for Children’s Mental Health treatments for Conduct Disorder in children. Journal of Child Psychology and Psychiatry, 38, 161–178. Kennedy, S., Rapee, R. & Edwards, S. (2009). A selective intervention program for inhibited preschool-aged children of parents with an anxiety disorder: effects on current anxiety disorders and temperament. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 602–609. Kessler, R., Berglund, P., Demler, O., Jin, R. & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM–IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602. Kiff, C.J., Lengua, L.J., & Zalewski, M. (2011). Nature and nurturing: Parenting in the context of child temperament. Clinical Child and Family Psychology Review, 14, 251–301. Kim-Cohen, J., Caspi, A., Moffitt, T. E., Harrington, H., Milne, B. J., & Poulton, R. (2003). Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. Archives of General Psychiatry, 60(7), 709–717. Kochanska, G. (1991). Socialization and temperament in the development of guilt and conscience. Child Development, 62, 1379–1392. Kochanska, G. (1997). Multiple pathways to conscience for children with different temperaments: From toddler hood to age 5. Developmental Psychology, 33, 228–240. Lahat, A., Hong, M. & Fox, N. A. (2011). Behavioural inhibition: is it a risk factor for anxiety? International Review of Psychiatry, 23, 248–257. Leijten, P., Shaw, D. S., Gardner, F., Wilson, M. N., Matthys, W., & Dishion, T. J. (2014). The Family Check-Up and service use in high-risk families of young children: A prevention strategy with a bridge to community-based treatment. Prevention Science, 1–10. Maughan, B. & Kim-Cohen, J. (2005). Continuities between childhood and adult life. The British Journal of Psychiatry,187,301–303. McCart, M. R., Priester, P. E., Davies, W. H., & Azen, R. (2006). Differential effectiveness of behavioral parenttraining and cognitive-behavioral therapy for antisocial youth: a meta-analysis. Journal of Abnormal Child Psychology, 34(4), 527–543. McClowry, S. G. (2003). Your Child’s Unique Temperament: Insights and Strategies for Responsive Parenting. Champaign, Illinois: Research Press. McClowry, S.G., & Collins, A. (2012). Temperament-based intervention: Reconceptualized from a response-tointervention framework. In: M. Zentner & R.L. Shiner (Eds), Handbook of Temperament, pp 607–626. The Guildford Press: London. McClowry, S. G., Snow, D. L., & Tamis-LeMonda, C. S. (2005). An evaluation of the effects of INSIGHTS on the behavior of inner city primary school children. Journal of Primary Prevention, 26(6), 567–584. McClowry, S.G., Snow, D.L., Tamis-LeMonda, C.S., & Rodriguez, E.T. (2010). Testing the efficacy of INSIGHTS on student disruptive behavior, classroom management, and student competence in inner city primary grades. School Mental Health, 2, 23–35. McMahon RJ. (2008). Parent training interventions for preschool-age children. 2nd ed. In: Tremblay, R.E., Boivin,

Belsky, J. & Pluess, M. (2009). Beyond diathesis stress: Differential susceptibility to environmental influences. Psychological Bulletin, 135, 885–908. Biederman, J., Faraone, S. V., Hirshfeld-Becker, D. R., Friedman, D., Robin, J. A., & Rosenbaum, J. F. (2001). Patterns of psychopathology and dysfunction in highrisk children of parents with panic disorder and major depression. The American Journal of Psychiatry, 158, 49–57. Carey, W.B., & McDevitt, S.D. (1978). Revision of the Infant Temperament Questionnaire. Pediatrics, 61, 735–739. Chess, S., & Thomas, A. (1986). Temperament in clinical practice. New York: Guilford Press. Chess, S., & Thomas, A. (1991). Temperament and the concept of goodness of fit. In J. Strelau & A. Angleitner (Eds.), Explorations in temperament: International perspectives on theory and measurement (pp. 15–28). New York, NY: Springer. Dadds, M. R, Allen, J. L., McGregor, K., Woolgar, M., Viding, E., & Scott, S. (2014). Callous-unemotional traits in children and mechanisms of impaired eye contact during expressions of love: A treatment target? Journal of Child Psychology and Psychiatry, 55, 771–780. Dadds, M. R., Spence, S. H., Holland, D. E., Barrett, P. M. & Laurens, K. R. (1997). Prevention and early intervention for anxiety disorders: a controlled trial. Journal of Consulting and Clinical Psychology, 65, 627–635. Dilalla, L. F., Kagan, J., & Reznick, J. S. (1994). Genetic etiology of behavioral inhibition among 2-year-old children. Infant Behavior and Development,17, 405–412. Eisenberg, N., Vaughan, G., & Hofer, C. (2009). Temperament, self-regulation, and peer social competence. In K.H. Rubin, W.M. Bukowski, & B.P. Laursen, (Eds), Handbook of Peer Interactions, Relationships, and Groups. New York: The Guilford Press. Frick P. J., Morris A. S. (2004). Temperament and developmental pathways to conduct problems. Journal of Clinical Child & Adolescent Psychology, 33, 54–68. Hudson, J. L., Dodd, H. F. & Bovopoulos, N. (2011a). Temperament, family environment and anxiety in preschool children. Journal of Abnormal Child Psychology, 39, 939–951. Hudson, J. L., Dodd, H. F. & Bovopoulos, N. (2011b). Temperament and family environment in the development of anxiety disorder: Two-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 1255–1264. Hudson, J. L., Newall, C., Rapee, R. M., Lyneham, H. J., Schniering, C. C., Wuthrich, V. M., Seeley-Wait, E., Edwards, S., & Gar, N. S. (2014). The impact of brief parental anxiety management on child anxiety treatment outcomes: a controlled trial. Journal of Clinical Child & Adolescent Psychology, 43, 370–380. James, A. A. C. J., Soler, A. & Weatherall, R. R.W (2005). Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews, 4, CD004690. Kagan, J. (1989). Temperamental contributions to social behavior. American Psychologist, 44, 668–674. Kagan, J. & Snidman, N. (2004). The long shadow of temperament. Cambridge, MA: Harvard University Press. Kazdin, A. (1997). Practitioner review: Psychosocial

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Allen: When one size doesn’t fit all: temperament-based parenting interventions M., Peters, R. (Eds). Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development and Strategic Knowledge Cluster on Early Child Development; 2008:1–9. Available at: www.child-encyclopedia.com/documents/ McMahonRJANGxp.pdf. Accessed [04.06.2014]. Miller, G.E., & Prinz, R.J. (1990). Enhancement of social learning family interventions for child conduct disorder. Psychological Bulletin, 108, 291–307. Monroe, S. M., & Simons, A. D. (1991). Diathesis-stress theories in the context of life stress research: Implications for the depressive disorders. Psychological Bulletin, 110, 406–425. Mrazek, P. J. & Haggerty, R. J. (1994). Reducing Risks for Mental Disorders. Washington, DC: National Academy Press. Nigg, J. (2006). Temperament and developmental psychopathology. Journal of Child Psychology and Psychiatry, 47, 395–422. O’Connor, E., Rodriguez, E., Cappella, E., Morris, J., & McClowry, S. (2012). Child disruptive behavior and parenting efficacy: a comparison of the effects of two models of INSIGHTS. Journal of Community Psychology, 40(5), 555–572. Pluess, M. & Belsky, J. (2013). Vantage sensitivity: Individual differences in response to positive experiences. Psychological Bulletin, 139(4) 901–916. Presley, R., & Martin, R.P. (1994). Toward a structure of preschool temperament: Factor structure of the Temperament Assessment Battery for Children. Journal of Personality, 62, 415–448. Rapee, R. M. (2013). The preventative effects of a brief, early intervention for preschool-aged children at risk for internalising: follow-up into middle adolescence. Journal of Child Psychology and Psychiatry, 54, 780–788. Rapee, R. M., Kennedy, S., Ingram, M., Edwards, S., & Sweeney, L. (2005). Prevention and early intervention of anxiety disorders in inhibited preschool children. Journal of Consulting and Clinical Psychology, 73, 488–497. Rapee, R. M., Kennedy, S., Ingram, M., Edwards, S., & Sweeney, L. (2010). Altering the trajectory of anxiety in at-risk young children. American Journal of Psychiatry, 167, 1518–1525. Rapee, R. M., Lau, E. X., & Kennedy, S. J. (2010). Cool Little Kids Anxiety Prevention Program. Sydney, Australia: Centre for Emotional Health Macquarie University. Rapee, R.M., Schniering, C.A., & Hudson, J.L. (2009). Anxiety disorders during childhood and adolescence: Origins and treatment. Annual Review of Clinical Psychology, 5, 311–341. Rothbart, M. K., Ahadi, S. A., Hershey, K. L., & Fisher, P. (2001). Investigations of temperament at 3–7 years: The Children’s Behavior Questionnaire. Child Development, 72, 1394–1408. Rothbart, M. K., & Bates, J. E. (2006). Temperament. In N. Eisenberg, W. Damon, & R. M. Lerner (Eds.), Handbook of child psychology: Vol. 3, Social, emotional, and personality development (6th ed., pp. 99–166). Hoboken, NJ: Wiley. Rothbart, M. K., & Rueda, M. R. (2005). The development

of effortful control. Developing individuality in the human brain: A tribute to Michael I. Posner, 167–188. Sanders, M.R. (2012). Development, evaluation, and multinational dissemination of the Triple P-Positive Parenting Program. Annual Review of Clinical Psychology, 8, 345–79. Sanders, M.R., Pidgeon, A.M., Gravestock, F., Connors, M.D., Brown, S., & Young, R.W. (2004). Does parental attributional retraining and anger management enhance the effects of the Triple P-Positive Parenting Program with parents at risk of child maltreatment? Behavior Therapy, 35, 513–535. Sanson, A., Hemphill, S. A., Yagmurlu, B., & McClowry, S. (2011). Temperament and social development. In P. K. Smith & C. H. Hart (Eds.), The Wiley-Blackwell handbook of childhood social development (2nd ed.). Oxford: WileyBlackwell. Schwartz, C., Kunwar, P., Greve, D., Kagan, J., Snidman, N., & Bloch, R. (2012). A phenotype of early infancy predicts reactivity of the amygdala in male adults. Molecular Psychiatry, 17, 1042–1050. Scott, S., & Dadds, M. R. (2009). Practitioner review: When parent training doesn’t work: Theory-driven clinical strategies. Journal of Child Psychology and Psychiatry and Allied Disciplines, 50, 1441–1450. Scott, S., Knapp, M., Henderson, J., & Maughan, B. (2001). Financial cost of social exclusion: follow up study of antisocial children into adulthood. British Medical Journal, 323, 191–194. Shiner, R.L. & Caspi, A. (2003). Personality differences in childhood and adolescence: Measurement, development, and consequences. Journal of Child Psychology and Psychiatry, 44, 2–32. Snell, T., Knapp, M., Healey, A., Guglani, S., Evans-Lacko, S., Fernandez, J-L., Meltzer, H. et al. (2013). Economic impact of childhood psychiatric disorder on public sector services in Britain: estimates from national survey data. Journal of Child Psychology and Psychiatry, 54, 977–985. Stringaris, A. (2011). Irritability in children and adolescents: A challenge for DSM-5. European Child & Adolescent psychiatry, 20, 61–66. Thomas, A., & Chess, S. (1977). Temperament and development. New York: Brunner/Mazel. Thomas, A., Chess, S., & Birch, H. G. (1968). Temperament and behavior disorders in children. New York: New York University Press. Thomas, A., Chess, S., Birch, H.G., Hertzig, M.E., & Korn, S. (1963). Behavioral indviduality in early childhood. New York: New York University Press. Wachs, T. D. (2006). Contributions of temperament to buffering and sensitization processes in children’s development. Annals of the New York Academy of Sciences, 1094, 28–39. Webster-Stratton, C. (2011). The Incredible Years Parents, Teachers, and Children Training Series: Program Content, Methods, Research and Dissemination, 1980–2011. The Incredible Years Inc.: Seattle, Washington.

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ACAMH Occasional Papers No. 33

Making parenting work for children’s mental health Edited by Cecilia A. Essau and Jennifer L. Allen

Occasional Papers Series Editor: Cecilia Essau

Full Book Publication Information: Table of Contents, Chapter Abstracts and doi information is available at: http://bit.ly/1QPhaeI

How to Cite: Whole Book: C.A. Essau & J.L. Allen (Eds), Making parenting work for children's mental health. ACAMH Occasional Paper 33. London: Association for Child and Adolescent Mental Health. doi:10.13056/OP33

Chapters: Author, X.X. [All Authors] (2015]. Chapter title. In C.A. Essau & J.L. Allen (Eds), Making parenting work for children's mental health. ACAMH Occasional Paper 33 (Chap Y, pp. aa-dd), doi:10.13056/OP33.z [see Chapter title pages for doi end suffix] London: Association for Child and Adolescent Mental Health.

Contents Introduction: Making parenting work for children’s mental health Cecilia A. Essau and Jennifer L. Allen

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Chapter 1 Lessons learned from introducing, researching, and disseminating the Incredible Years programmes in Wales 3 Judy Hutchings Chapter 2 When one size doesn’t fit all: temperament-based parenting interventions Jennifer L. Allen

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Chapter 3 Making parenting work for anxious children Sam Cartwright-Hatton

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Chapter 4 Callous–unemotional traits and the re-evaluation of parent training for child conduct problems David J. Hawes

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Chapter 5 Tuning in to Kids: an emotion-focused parenting intervention for children with disruptive behaviour problems 41 Sophie S. Havighurst, Christiane E. Kehoe, Ann E. Harley and Katherine R. Wilson Chapter 6 Psychosocial interventions for social communication, repetitive, and emotional-behavioral difficulties in children and young people with autism spectrum disorder: an update on effectiveness and the role of caregivers 51 Francisca J. A. van Steensel and Iliana Magiati Chapter 7 Viewing selective mutism as a phobia of talking: the importance of accurate conceptualisation for effective clinical and parental management 61 Maggie Johnson and Alison Wintgens

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Introduction: Making parenting work for children’s mental health Cecilia A. Essau1 and Jennifer L. Allen2 University of Roehampton, London, UK UCL Institute of Education, London, UK

1 2

doi:10.13056/OP33.c

Parenting has been identified as a key factor associated with childhood illnesses, spanning beyond mental health problems. The long-term significance of this becomes more apparent as understanding grows regarding the link between experiences during childhood and longterm outcomes. Varying levels of significance attached to different stages in a child’s development, from birth through to adulthood, and recent research investigating the influence of parenting on each of these stages has received consideration from services and governments across the world. The following papers further highlight the importance of parental influence in the prevention and intervention of children with emotional, neurodevelopmental and behavioural disorders. This Occasional Paper was conceived following the Emanuel Miller Memorial Lecture and Annual Conference which was held in March 2013. The event was titled “Making Parenting Work for Children’s Mental Health”. We are very fortunate to have received contributions from authors of parenting interventions for a wide range of child and adolescent emotional and behavioural problems. Judy Hutchings, one of the speakers at the conference, writes about her experience in implementation and dissemination of the Incredible Years (IY) programme in Wales. The IY programme was initially developed 30  years ago at the University of Washington (Webster-Stratton, 2011) as a prevention and treatment programme for conduct disorder and other difficulties. The main features of this intervention include teaching participants new skills, such as problem solving using role play, goal setting and home activities. The programme has since then been evaluated and implemented in various countries and different service settings, results of which indicate improvement in parental mental health, parenting skills and ultimately child problem behaviours. David Hawes outlines growing evidence that children with conduct problems are a highly heterogeneous population, with subgroups of such children following distinct risk pathways associated with distinct treatment needs. One important distinction is made between emotionally-dysregulated (‘hot tempered’) children versus those with callous–unemotional (CU) traits, who demonstrate more severe problems and are less responsive to current parenting interventions. Drawing on

emerging evidence concerning the interplay between parenting, CU traits, and conduct problems, he examines numerous ways in which the planning and delivery of parenting interventions may be improved to better promote the behavioural and emotional development of distinct subgroups of children with conduct problems. Sophie Havighurst and her colleagues give a comprehensive review of their Tuning in to Kids (TIK) programme which describes how emotion-focused parenting can be employed in interventions for disruptive problem behaviours. Taking roots from mindfulness, emotion-focused cognitive therapy and attachment theory, the TIK programme highlights the importance of emotionally responsive parenting. By providing parents the opportunity to communicate their understanding of emotions and offering the child appropriate words to express their emotions, the programme further encourages close parent–child connections while improving children’s internal and external behavioural problems. Children develop the ability to recognise emotional experiences and appropriate ways to respond to parents’ emotions and regulate their own emotions. Jennifer Allen explains the importance of personalising treatment based on child temperament. Temperament theory and research helps us to understand the substantial heterogeneity in child psychopathology and social-emotional development. The ‘goodness of fit’ framework (Thomas & Chess, 1977) provides guidance as to how parents can best support their child to promote his or her social-emotional competence and healthy psychological adjustment. Temperament-based parenting programmes involve the modification of existing parenting strategies and/or development of innovative new strategies to achieve optimal outcomes for children based on their unique temperament profile. In this manner, treatment is individualized or personalised for children and families, with the aim of achieving improved treatment outcomes. Sam Cartwright-Hatton describes her Timid to Tiger programme, which is a parenting-based approach to managing anxiety in young children. Parents learn a new approach to managing their children, using attachment-based play, praise and reward for confident behaviours, and planned ignoring for unwanted behaviours. Parents are also taught simple cognitive-behavioural

ACAMH Occasional Paper 33: Making Parenting Work for Children’s Mental Health © 2015 Association for Child and Adolescent Mental Health. All rights reserved.

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Essau & Allen: Introduction: Making parenting work for children’s mental health techniques for managing their children’s fear and worry. The outcome from their randomized controlled trial showed that those in the intervention group, compared to those in a waiting list group, were approximately seven times more likely to be anxiety-free than the untreated control group at the end of treatment, with treatment gains maintained over 12 months. Bonny van Steensel and Magiati review psychosocial interventions which target social skills, internalizing and externalizing difficulties in children and young people with ASD. These interventions use primarily behavioural and/or cognitive behavioural approaches. Results of these approaches indicated general improvements in social competence and friendships, however the significance of parental influence is not considered in these treatment programmes. As for repetitive behaviours, applied behavioural strategies that target stereotypical behaviours resulted in positive outcomes, whereby the role of parents in implementing strategies that involve redirecting and monitoring repetitive behaviours is highlighted.

Maggie Johnson and Alison Wintgens give an overview of what is known about selective mutism and made a persuasive argument in support of selective mutism having a stand-alone diagnosis under Anxiety Disorders, as adopted in DSM-5. As selective mutism involves more factors than the conditioned fear response associated with Specific Phobia, they suggest using a multimodal approach to address the family and school’s role in maintaining the child’s mutism. We hope that the collection of seven papers stimulates readers’ interests in promoting a holistic and evidence-based approach, delivered through supporting better parenting.

References Thomas, A., & Chess, S. (1977). Temperament and development. New York: Brunner/Mazel. Webster-Stratton, C. (2011). The Incredible Years: Parents, Teachers, and Children’s Training Series. Seattle: Incredible Years Inc.

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Published 2015 by Association for Child and Adolescent Mental Health (ACAMH), St Saviour’s House, 39/41 Union Street, London SE1 1SD, UK Copyright © 2015, selection and editorial matter, Association for Child and Adolescent Mental Health (ACAMH); individual articles, the contributors and ACAMH All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any means electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A CIP catalogue record for this book is available from the British Library ISBN: 978-1-899176-24-3 No. 33 in the ACAMH Occasional Paper series; ISSN: 10956-5825 doi:10.13056/OP33.a How to cite Whole book: C.A. Essau & J.L. Allen (Eds), Making parenting work for children’s mental health. ACAMH Occasional Paper 33. London: Association for Child and Adolescent Mental Health. doi:10.13056/OP33 Chapters: Author, X.X. [All Authors] (2015). Chapter title. In C.A. Essau & J.L. Allen (Eds), Making parenting work for children’s mental health. ACAMH Occasional Paper 33 (Chap Y, pp. aa–dd), doi:10.13056/OP33.z [see chapter title pages for doi end suffix] London: Association for Child and Adolescent Mental Health.

Available from ACAMH, St Saviour’s House, 39/41 Union Street, London SE1 1SD, UK

ISBN 9781899176243

ISBN: 978-1-899176-24-3

9 781899 176243