We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Yeah, my name is Christina Stadler. I'm a professor for developmental psychopathology here in Basel. And I'm also working as a clinician, working with children and mainly with children or adolescents with disruptive behaviour disorders. So the most important recommendations of existing guidelines are the implementation of parent training programmes, child-focused programmes for older children aged 9 to 14, and multimodal intervention, especially in case of persistent and severe disruptive behaviour disorder. The effectiveness of an intervention is limited if there are specific risk factors in children or in parents when we focus on parent trainings. In children, one well-investigated risk factor is the specifier limited prosocial emotions or so-called callous-unemotional traits. There's a recent meta-analysis conducted by Perlstein and colleagues published in 2023. And he showed that interventions are effective for these children. However, DBD children with high callous-unemotional traits, they start and end treatment with more severe disruptive behaviour symptoms. Thus, they need more intensive, and I would suggest, more tailored intervention. Second, treatment effects are also lower and limited in socially or socioeconomically disadvantaged families, and especially in families where parents suffer from a mental illness. And additionally, we need adaptions for patients who come from different ethical contexts. So what we know is that children with elevated callous-unemotional traits show a reward-oriented learning style. So they are often incentive to punishment cues, that was the result that we also have shown in our own studies and our huge Euro FemNAT Consortium. And raising these children is often very stressful for parents. They react with harsh strategies and low parental warmth. And we know, in addition, that parental warmth can buffer the influence of callous-unemotional traits. And based on these results, we have to coach parents to engage in warm, emotionally-responsive parenting. Even though when it's so hard to raise these children, we have to enable parents to use more reward-based techniques. So this means to praise these children when they show positive behaviour and to use more individualised token economy instead of punishment-based disciplinary strategy. So even though timeout is more punishment-based strategy. And furthermore, I think we have to specifically address the children's insensitivity to distress cues. What we also know based on our research is that these kids often have problems to recognise emotions in the face of others. And that should also be in the focus of the treatment. And one approach that implemented these topics was Fleming and Kimonis. He adapted Parent-Child Intervention Therapy, PCIT. And one model in these PCIT for callous-unemotional children aims to better attend and to recognise emotions in others and how can parents help their kids to better recognise emotions in others Because PCIT is an intervention for parents and their children. And I would add that it's also often important to help parents to improve their own emotional regulation skills because they are often overwhelmed by negative emotions when they are confronted with aggressive behaviour of their children. I wanted to add that we also have to differentiate between primary and secondary variants of callous-unemotional traits. There is not one phenotype. And that's important because the two variants probably need different intervention approaches. In contrast to the primary variants, the secondary variant is less genetically determined and characterised by comorbid anxiety and a history of trauma. And it's argued that these early traumatic experience early in childhood may lead to a deactivation of the emotional system. The children become emotionally blunted. Thus, in this variant, we can assume that callousness is more a coping mechanism and less a deficient learning mechanism. So to sum up, I think the presence of limited prosocial emotion clearly is a risk factor for maladjustment and a chronic course of disruptive behaviour disorder. And therefore, it's not surprising that many of these children and adolescents often are placed also in correctional or forensic institutions. And due to the problems of these children, they are also challenging for caretakers and staff in these institutions. And unfortunately, often their evidence-based interventions are lacking. START NOW is an intervention that specifically was developed for those settings with an urgent need for interventions. It was developed by Professor Trestman in the United States. And it was adapted here in Basel together with my team. Yes, that now is an integrative and a comprehensive intervention programme. That means that the treatment is not working only with the child, or the young person, or the adult, but with the whole setting. So we can say that the aim of START NOW is to provide staff and caregivers with the knowledge necessary to deliver a short and evidence-based but also cost-effective intervention in their specific setting. And affected persons in the institutions are trained within START NOW to better deal with strong emotions, to learn, for example, what is at the top of emotion, the top of anger, and to better attend and respect also emotions in others. These are core deficits in disruptive behaviour disorder. And I would point out that disruptive behaviour disorder is not only characterised by deficiencies in appropriate behaviour but by deficits in emotion processing. And START NOW aims to take this into the focus of the treatment. And that's what we also see or what is the result of many studies that children, adolescents, and adults with disruptive behaviour have problems in emotion processing. Another core element of START NOW is maybe that we also integrate sessions on depressive behaviour or substance abuse because what we also know and what we have seen in our studies is that the comorbidity of these disorders is extremely high in conduct disorder or oppositional defiant disorder and only to focus on aggressive behaviour in our intervention would not be so good. START NOW is a manualized. Adolescents have a workbook, for example. That's also important, we use very simple language. We included a lot of cartoons and video clips. And peers were included in the development of START NOW. Our aim is or our aim was to make the programme understandable and attractive because motivation of treatment often is not so high in this patient group. And the skills trainings, START NOW also has skills training usually provided by a social worker and a psychologist, or therapist, or it's provided in an interdisciplinary team. And the involvement from caretakers, in my opinion, in my view is very important because the social worker is together with the child or the young person the whole day and he can remind the child in a stressful situation to use the skill he has learned in the skills training. And we are convinced that this might increase the efficacy of the skills training because skills training per se are not so efficient. That was shown by a huge meta-analysis conducted by Beelmann in 2021 comprising more than 130 randomised-controlled trials. And Beelmann found that post-intervention effect of skills training of occurrence d, 0.25. So that's only a modest effect. But however, we can assume that the efficacy of skills training is higher when the skills training is embedded in the setting where the children live. Simply learning new skills is one thing, but applying them in situations that are stressful is something else. And the use of new skills instead of the old ones, I think this is possible only with guidance, only with the support of caretakers, for example, that we have a better transfer of the learned skills into daily life. I mentioned already that START NOW was developed for settings like the youth welfare setting or the forensic setting where such interventions are urgently needed. And START NOW comprises the pre-training for the staff who works in the settings. And future facilitators who will deliver the skills training in their respective setting are trained in the two days' pre-training, for example, in trauma-sensitive care, in motivational interviewing techniques, in basics in CBT or acceptance commitment therapy. And they are trained how to run the sessions of the skills training. They learn how to conduct functional analyses of emotions and behaviour or exercises in mindfulness. And in the pre-training, we play the group sessions and we practise, for example, how to deal with resistance, where many of these adolescents are not willing or often have a low motivation and they are resistant. And we play this in the pre-training and how the facilitators, how the staff can deal with this resistance, how they can use motivational interviewing techniques to elicit behavioural change, that's very important. As mentioned, we use very simple language and we break down helpful skills into five basic strategies. These are the START NOW strategies. And each letter stands for one skill. So S stands for Slow down. And here we train mindfulness skills to calm down, for example. In the Take a step back session, the power of thoughts is discussed. Here we introduce functional analysis in order to understand the impact of thoughts on emotions and behaviour. Thoughts often plop out like in a popcorn machine and that can be very, very stressful. And we train what can we do when we are hooked by these negative thoughts, let's take a step back. Accept is also an important skill and important to learn how to accept painful emotions and to accept painful or strong emotions like anxiety or to be a bit stressed. It's very important in order to follow goals and to follow dreams, for example. I have to accept my anxiety to pass, for example, an exam, et cetera. The strategy Accept recovers social competencies. For example, how can I set boundaries? How can I communicate to reach what is important for me. Take action, the last capital in the word START, is the last strategy. And here we teach how to set goals, how can we overcome barriers to follow our goals. Even though START NOW is a transdiagnostic intervention, it often was delivered in forensic settings and in youth welfare settings. And in our European Consortium, we tested the efficacy start now in youth welfare institutions, and especially in youth welfare institutions, the prevalence of conduct disorder and oppositional defiant disorder is very high, about 60%. And then we tested the efficacy in three countries, in Switzerland, in Germany, and in the Netherlands. And the question was, is an intervention where we delivered START NOW as an add-on intervention efficient to reduce oppositional and aggressive behaviour compared to standard care in youth welfare institutions? And our results indicate that all adolescents in youth welfare institutions showed less CD and ODD symptoms, Oppositional Defiant Symptoms, and conduct behaviour symptoms, less aggressive behaviour after 12 weeks. That's in both groups. But there was a significant group difference directly after the intervention not in the primary outcome variable that was assessed in the psychiatric interview. There the significance was not-- there was not a significant difference, but in other variables. So parents rated less irritability and there was a stronger reduction also in staff rated versus behaviour. It was with a medium effect size. But I have to mention this, we had one primary outcome variable and the other difference was not significant. But three months after end of the intervention, also in this primary outcome variable, we have a significant reduction in those who received START NOW compared to standard care. That's 12 weeks after the end of the training, participants of the START NOW training further improved and we only found a further decline in aggressive behaviour symptoms in those who received START NOW and not in those who received standard care. Thus, to summarise this, we found a delayed treatment effect regarding the primary outcome variable. And we suggest that this training of staff and the use of these motivational interviewing techniques and in-vivo coaching was crucial for this delayed intervention effect. Because the staff applied these strategies they learned in the pre-training for a longer time, not only during the skills training. The skills training lasted only 12 weeks. In general, I would recommend that teaching trauma-sensitive care or the basic in Cognitive Behaviour Therapy, CBT, but especially all these motivational interviewing techniques are very important. Trauma-informed care seeks to understand how early negative experiences or psychosocial risk factors impact the functioning and emotion regulation in children and adolescents. For example, in persons with trauma history, aggression can be a strategy to cope with stressful emotions. Anger often is easier to deal with than feelings of sadness or disappointment. So anger might be seen as a coping mechanism. And to better understand these underlying reasons for aggressive behaviour, it's helpful also for caretakers to deal with own stressful emotions. Staff especially in correctional facilities, but also in youth welfare institutions, and even in schools, are often feeling helpless, angry, incompetent when they are confronted with aggressive oppositional behaviour or repeated assaults of the children and adolescents. And it's well documented this daily stress leads to a high burnout in staff and also in a high cortisol level, for example. That's really a stressful job. Thus, a further aim of staff now is to apply these learned skills, slow down, take a step back, accept, that these strategies are also applied by the staff, by caregivers, by teachers to cope with emotional and stressful demands in daily life. The aim is to foster resilience not only in the patients or in the children, but to foster a resilience also in the caregivers and in the staff. And that's very important, in my opinion, because what we know is that a setting that is safe and secure, that this setting is protective also for the development of mentally ill children. And indeed, in qualitative analysis we conducted, we have seen that stuff indeed applied these START NOW skills. And in case the staff applies these START NOW skills, staff and caregivers are also a model of how to use these skills. And the staff guides children how they can use it. So this integrated approach, in my opinion, is very important. So I think what's clear is that also not only the staff, but teachers experienced stress, but that's also true for parents. And what we do know is that stress, mental illness in parents, but also socioeconomic disadvantages are also important risk factors for the development of disruptive behaviour disorders. And therefore, these risk factors have to be considered in the treatment of children with disruptive behaviour disorders. Mentally ill parents often experience strong emotions in daily life. They are overwhelmed by their emotions. And they struggle in their personal and social relationships with a partner, but also with their own kids. And these difficulties can interfere with their ability to provide a stable, safe environment. And this is a risk factor for the development of the children. And without sufficient support, these risk factors have a negative impact on both the cause of the parent's illness, but also for the child and the development of the child. And another factor I wanted to mention is that in these families where there's a high load of stress or disadvantaged parents with a high bunch of risk factors, unfortunately, we do have a high drop out rate in parent training programmes. They do not show up because the stress is simply too high to attend these programmes. So how can we better reach and engage these families? One issue is or one point is that the way we communicate is important. Although, here it is useful to use motivational techniques to engage these families, instead of selling tips or trying to convince parents that it is necessary to be in the parent training or to sell tips, we have to empower these parents and we have to emphasise teamwork. The well-known psychotherapist Winnicott describes all these parents as good enough parents. They try to do the best what they can. And we should approach them with this positive attitude. I think, otherwise, we will lose them. And finally, I would recommend intervention approaches that include both children and parents at the same time. In our classic treatment approaches, we treat mentally ill child in adolescent psychiatry and we treat parents in adult psychiatry. And I think it would be promising to have more comprehensive approaches, for example, parent-child clinics. START NOW was specifically developed for real-world setting. But we have learned that implementation is not always easy. And now there is huge research in implementation research because this is really very important to consider. And what we have learned is that the effectiveness of an intervention strongly is influenced by how well the programme is implemented in the institution. The question is, for example, are there sufficient personnel resources available? Is the treatment programme accepted by everyone? Are there employees behind the concept? Or does the implementation mean additional stress in everyday working life? These are variables that are really important not only for the youth welfare institutions or correctional facilities, but also for the implementation of preventive approaches in schools, for example. And START NOW is also implemented in schools. And in schools Nowadays, , there is a high workload for teachers. And we have seen that it is not easy to implement preventive programmes when this workload is so high, for example. Often resources are lacking and there is a high burden on staff, as I mentioned, which really makes it difficult to implement evidence-based interventions into these settings. Thus, politicians should also take this seriously and spend enough money to improve current conditions in schools, in youth welfare institutions, in correction facilities. So the good thing is we do have evidence-based intervention approaches for disruptive behaviour disorders. However, children and their families who are, for example, marginalised because of race, ethnicity, socioeconomic status, neighbourhood context, et cetera, receive often fewer and lower quality mental health services relative to non-marginalised populations or the treatment is not adapted to these populations. So we need more effort to reach these families who are in need. And I think we have to find solutions in order to reduce this high drop out often in families who are highly stressed or who are disadvantaged. A recent systematic review and meta-analysis conducted by Hodson and colleagues this year revealed that incentives can increase the engagement of parents in parent training programmes, especially in parents from low income backgrounds and families with an ethnic or racial background. While some politicians may be critical to give incentives, it's important to point out that every dollar or every euro that is investigated early in the treatment of aggressive or disruptive behaviour will ultimately reduce many of the expenses required later on for these children or adults. So in sum, I would say more money should be made available overall for the implementation of evidence-based intervention for these children and their families. There are still far too many children and young people who do not receive appropriate care and appropriate help. And I would suggest that money should also be spent to realise more comprehensive and multi-level intervention approaches. Intervention approaches, for example, where parents and children are in the focus of the intervention. Unfortunately, our current health insurance system hardly covers the cost for such more comprehensive approaches. And lastly and finally, it should also be pointed out that studies also indicate that preventive programmes, for example, in schools also have a positive effect in reducing the risk of developing disruptive and aggressive behaviour. Thank you very much for your attention. [STIRRING MUSIC]