Kid gloves: how to treat children with callous traits
Remorselessly self-centred and indifferent to others suffering, they’re a parents’ worst nightmare. Can callous children be helped?
By age six he had tried to stab his mother with a knife, pointed a loaded airgun at his parents and attacked his sister by spraying chemicals in her face and pouring petrol on her. The special education preschool he attended expelled him for hitting, kicking and spitting on children and teachers. At home, he lit fires inside the house, urinated on furniture and impulsively ran into the middle of the street, heedless of oncoming traffic. His primary school teachers reported that he would lie, steal and tell elaborate stories about false events. His lack of remorse was so pronounced that he often laughed after assaulting another child or being destructive. When his mother asked him why he was so violent, he replied: “I’m trying to scare you.”
Eva Kimonis was a research psychologist in southern Florida when she first encountered Luke*, a five-year-old boy who exhibited all the unnerving traits of what her profession describes as “callous-unemotional” children. These are the kids that US novelist Lionel Shriver brought to life in her scarifying novel We Need To Talk About Kevin — remorselessly self-centred, seemingly indifferent to other people’s suffering and significantly at risk of growing up to become adult psychopaths. Kimonis, 39, has been immersed in their world since her university days, when she first began her up-close studies of callous and sadistic young people. It’s a line of work that in 2013 brought her to Sydney, which has become a centre of research into possible ways of preventing cruel children from turning into psychopathic adults.
Down the hall from her tiny 11th floor office in the psychology faculty of the University of NSW is a carpeted, spartan room equipped with a couple of armchairs, a child-sized plastic table and chairs and a long mirror along one wall. It’s here, in the UNSW Parent-Child Research Clinic, that some of the most troubled and violent preschool children in the state have been brought by their troubled parents. The mirror is one-way; on its other side is a small room in which Kimonis and her team of behavioural therapists watch child and parent interact, transmitting instructions to parents via a Bluetooth earpiece. The aim, in the professional argot, is to use “child-directed interaction” to achieve “compliance with commands”.
The dry terminology doesn’t quite capture the high dramas that regularly erupt inside that small room. The chairs are leather or plastic because of the children’s capacity for spitting or urinating; the toys are lightweight because they tend to become projectiles; some of the staff wear knee-high boots to guard against shin-kicks. “We’ve had smashed windows, lots of broken things — there’s a lot of aggression,” acknowledges Kimonis. “But we’re right there with the parent.”
A typical participant is five-year-old Matthew from rural NSW, whose case history has been detailed by one the clinic’s psychologists, Georgie Fleming. Matthew was referred to the clinic because of unprovoked attacks on his younger brother and the family pets; his multiple daily temper tantrums involved crying, screaming and hitting; at school he bullied special-needs children. In the clinic, he “kicked, hit, spit and swore at his mother, and attempted to ‘strangle’ her by grabbing her neck”. Sent to a time-out room, he threw the door open with such force that it broke a window. Later he kicked his mother in the face, without any apparent remorse.
This lack of empathy is a defining characteristic of callous-unemotional children, a trait they share with those on the autism spectrum. But the children being treated at UNSW exhibit none of the repetitive tics of autism; their defining traits include a lack of guilt about their destructive violence and an indifference to either punishment or personal consequences such as failure at school. Most unnerving is the way many can quickly switch between emotional states, from compliant to violent, in pursuit of their desires. Most have already undergone the treatment regimens for attention deficit/hyperactivity disorder and oppositional defiant disorder without significant improvement.
As a PhD student in New Orleans, Kimonis interviewed scores of teenage prison inmates with callous traits, measuring their responses to images of human distress. They were found to have a markedly muted reaction to the suffering of others, a result that has since been mirrored in brain-scans of younger callous-unemotional children. “There is a lot of research evidence which shows that the brains and physiology of children with callous traits are different,” she says. “These children don’t respond to emotion in the same way as others, even other children with conduct problems. Most children with classic conduct problems struggle to control their emotions and act out impulsively, but then feel badly afterwards. Kids with callous traits are on the opposite end of the spectrum; there is not a lot of emotionality behind their anti-social behaviour, and they don’t respond appropriately to emotions in others.”
The notion of a child psychopath — the so-called “bad seed” — puts a chill in any parent’s heart. Cases such as the 1993 torture and murder of British toddler James Bulger by two 10-year-old boys exert an enduring ghastly fascination, and even experts in the field are divided about how to approach the study and treatment of such children. Psychopathic adults are generally regarded as untreatable, and some psychologists question the ethics of placing a similar label on children. John Edens, a clinical psychologist at Texas A&M University in the US, has described it as a “ruinous diagnosis” for both child and parents. But Kimonis is among a growing number of researchers who believe that early intervention could help divert children away from full-blown psychopathy. As a student, she was so fascinated with the subject that she moved to the University of New Orleans to study under Professor Paul Frick, who pioneered the identification and study of children with callous-unemotional traits.
Evidence that psychopaths may suffer an organic brain dysfunction has grown in recent years following studies of children and adolescents. MRI scans of teenagers who score highly on a psychopathy checklist often show marked anatomical differences in their brains; one study showed that three-year-olds who displayed minimal reaction to blasts of white noise went on to have a high incidence of adult criminality two decades later. But not every callous child grows into a psychopathic adult — one study estimated the number to be as low as 14 per cent — and the reasons for that remain opaque.
Kimonis cautions that it’s still unclear whether the changes to brain function that have been observed are genetic or triggered by outside forces such as exposure to drugs and stress in utero or early childhood trauma. The case of Luke, whom she encountered during her clinical residency at the University of South Florida in 2011, suggests how difficult it is to disentangle root causes.
Luke’s mother was an opioid abuser and he was adopted shortly after his birth. As an infant he suffered from a staph infection and delayed speech, engaged in toe-walking and underwent a brain scan because of “staring spells”. He struggled to sleep at night and his behaviour problems at age two were severe enough to merit special education classes. By the time he came to Kimonis’s clinic at age five, he was taking five prescription drugs, including dextroamphetamine and an antipsychotic, for oppositional defiant disorder and ADHD.
Pleasant and co-operative in the clinic at first, he began violently ripping posters off the walls and tearing them up when pushed to comply with simple requests. He was violent towards people and animals, and unfazed by punishment: his mother would send him to a “time-out” room on average 16 times a day, and his school said that he “does not seem to be bothered by consequences”.
At the time, Kimonis was working on her first attempts at devising a treatment strategy for such intractable cases. “For the most part, the field of callous-unemotional traits and psychopathy is heavily dominated by trying to understand the causes,” she says. “There wasn’t a lot of work on treatment until relatively recently.” At her clinic, she was using a real-time therapy technique in which the therapist watches parent and child interact through a one-way mirror, offering advice and instructions via a microphone transmitting to the parent’s earpiece. The results showed that conventional punishment/reward techniques had no effect on callous-unemotional children, who were indifferent to time-outs and became enraged when demands were denied. Luke was among the first children on whom she tried a new therapy program: he was taught to better recognise other’s emotions, and his parents were instructed to de-emphasise punishment and reward even mildly positive behaviour.
The idea drew in part on the work of Professor Mark Dadds, a psychologist who was then at UNSW and among the world’s leading researchers on childhood conduct disorders. With his colleague David Hawes, now an associate professor at The University of Sydney, Dadds had developed a widely used therapy program for disruptive children and was testing how well it worked for callous-unemotional kids, making UNSW one of the rare institutions in the world searching for solutions. “UNSW was doing pioneering work,” Kimonis recalls. “There were only a handful of people in the US focusing on treatment of these kids at the time. Mark Dadds and David Hawes were using a different program to mine but it was their work that drew me here.” In 2013 she emigrated here with her husband to work with Hawes and Dadds, who have both since moved to Sydney University but continue to collaborate with her.
At UNSW, Kimonis set up her interactive clinic, with its one-way mirror and audio monitoring system. Her work in Florida had shown promising results — Luke, for instance, had recorded a 40 per cent decline in callous-unemotional traits after five months. In Sydney, Kimonis recruited 23 families whose three to six year-old children showed callous traits, enrolling them in a program of 21 weekly one-hour coaching sessions. Only three of the children were girls, reflecting the preponderance of males who exhibit these disturbing traits. The results of the therapy, published in the Journal of Clinical Child and Adolescent Psychology in August, showed that 75 per cent of the children recorded a “clinically significant” reduction in conduct problems three months after the program ended; nearly 70 per cent showed a “reliable improvement” in callous-unemotional traits.
Kimonis, now an associate professor at UNSW, acknowledges the limitations of the study: only 17 families completed the program, which was conducted in a clinical environment rather than the natural chaos of a household; and although many parents reported significant increases in their child’s empathy, that was not reflected in tests on the children, only about half of whom showed a reliable improvement. “Parents were telling us they saw significant changes,” says Kimonis. “For the first time ever their child would become upset if they saw the parent or an animal hurt, or they would try to engage in comforting behaviour after hurting them. But that was often not reflected in the psychometric tests of the children, so we’re investigating whether the techniques we are using to measure improvements in empathy need to be refined.”
The question of whether empathy can be taught is a vexed one in this field of research, because adult psychopaths are masterful at mimicking emotion to achieve their aims — one US prison-reform program to teach inmates empathic skills actually increased the offending of psychopathic prisoners by improving their ability to feign emotions such as regret. But Kimonis says that project is now decades old and used outdated and idiosyncratic methods that bear little resemblance to the evidence-based treatments of today. “There has been this longstanding pessimism about the treatability of this population,” she acknowledges. “But there is no science that says teaching these things to children makes them worse, and what we are seeing is that they display empathy in ways that appear to be genuine.”
Kimonis is now conducting a double-blind study to see if her therapy and parent-coaching techniques work better than standard treatments (or no treatment at all); she is also taking her methods out of the clinic and into a school in Sydney’s western suburbs. Her colleague Georgie Fleming, meanwhile, has been delivering therapy and coaching over the internet to 12 families who live in more remote locations, including five-year-old Matthew and his parents in rural NSW.
Like Kimonis, Fleming is cautious about overemphasising the destructiveness of these children, although she acknowledges they have their challenging moments. One child hit her in the face with a wooden train-track, which was “a good teaching moment about how you can tell if someone is in pain”; another child methodically tore every piece of paperwork in the play room into half-centimetre pieces, prompting a new clinic policy of laminating all paper materials. But such instances of hostility, she insists, are far outweighed by the rewards of the work. Matthew, for instance, has shown marked improvement since his in-home therapy. His mother reported that he now complies with more than 90 per cent of commands and appears both happier and more affectionate; his preschool teacher reported his callous-unemotional traits had reduced by a third.
“Each child brings something fresh and weird and wonderful,” she says, citing a four-year-old who conducted one clinic session entirely naked, and another who brought her the gift of a pet rock. “It’s a real privilege to work with these families and I’m absolutely floored by the commitment the parents give. The disruptive behaviours are always an exercise in problem-solving and everything else tends to be absolutely hilarious and heart-melting.
“I keep the pet rock on the shelf above my sink,” Fleming adds, “and that child still asks me whether I’m taking care of it.”
*Children’s names have been changed.
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