Parent Training and Emotion Coaching for Children with Limited Prosocial Emotions

患有对抗性违抗障碍(ODD)的儿童在儿童后期、青春期和成年期出现一系列负面结果的风险显著增加。这些结果可能包括青少年犯罪、早期和危险的性行为、不良的学业和职业适应、不良的人际关系，以及患各种精神障碍的风险增加。对ODD的有效治疗通常是基于基于社会学习的家长管理培训中心(�Parent Management Trading�，PMT)模式。尽管有强有力的证据证明PMT，但它并不适用于所有儿童，多达三分之一的儿童未能显示出可靠和持续的改善。有限的亲社会情绪(例如，缺乏内疚和同理心，冷酷地使用他人)似乎是减轻传统PMT影响的一个因素。有有限亲社会情绪的ODD儿童会出现更严重的行为问题，行为结果更差。因此，开发基于经验的方法来提高�传统�PMT对那些具有奇怪和有限亲社会情绪的儿童的有效性是重要的。最近的元分析研究表明，成功的基于家庭的干预方法的一个关键组成部分是向父母传授与情感交流相关的技能。鉴于有证据表明，患有有限亲社会情绪的ODD儿童在情感意识/识别和同理心方面存在缺陷，在传统的PMT中纳入以情感为重点的干预(这并不是PMT的重点)应该会改善这些儿童的结局。 与R34机制的目标一致，本应用程序的主要目标是开发和测试与循证PMT计划相结合的短暂情绪指导(EC)干预的可行性，帮助不顺从的儿童(HNC；Forward&McMahon，1981；McMahon&Forward，2003)，用于临床转介的具有有限亲社会情绪的ODD儿童。本研究的具体目标是：1)开发和完善基于经验的HNC-EC组合父母教养干预，以减少具有奇怪和有限亲社会情绪的儿童的CP；评估后一项临床试验的可行性，方法是：a)在社区精神卫生中心环境下，对已被转介接受显著水平的反对行为(且亲社会情绪也有限)的母亲及其3-7岁儿童与HNC单独进行比较，对新开发的HNC-EC干预进行试点测试，以及b)确定与单独使用HNC相比，HNC-EC干预的治疗可行性(家庭和治疗师层面的可行性、治疗保真度、参与者满意度)和研究可行性。虽然试点研究不应用于估计效应大小(Kraemer等人，2006年；Sherrill等人，2009年)，但我们将探索数据中的趋势，以便于考虑稍后在更大试验中进行统计建模的可能设计。有希望的发现将成为随机临床结果研究的基础，比较HNC单独和EC联合干预对有奇怪和有限亲社会情绪的儿童的影响。如果这种联合干预(重点是改善这一难以治疗的人群的结果)被证明是有效的，它将是第一批针对与儿童有限亲社会情绪有关的已知发育机制的干预措施之一。鉴于早发CP和有限亲社会情绪的儿童以异常的社会和经济成本增加了多种负面后果延续到成年的可能性，提高对PMT的应答率(这是一种低成本、低限制性的干预措施)将对公共卫生产生重大影响。

Children with oppositional defiant disorder (ODD) are at significantly increased risk for a host of negative outcomes in later childhood, adolescence, and adulthood. These outcomes can include delinquency, early and risky sexual behavior, poor academic and occupational adjustment, poor interpersonal relations, and increased risk for various mental disorders. Effective treatment for ODD has typically been based on a social learning-based �parent management training� (PMT) model. Despite strong evidence for PMT, it is not effective with all children, with up to one third failing to show reliable and sustained improvement. Having limited prosocial emotions (e.g., lack of guilt and empathy, callous use of others) appears to be one factor that mitigates the effects of traditional PMT. Children with ODD with limited prosocial emotions present with more severe conduct problems and have poorer behavioral outcomes. It is therefore important to develop empirically based methods to enhance the efficacy of �traditional� PMT for those children with ODD and limited prosocial emotions. Recent meta-analytic research indicates that one key component of successful family based intervention approaches involves teaching parents skills related to emotional communication. Given evidence that children with ODD with limited prosocial emotions have deficits in the awareness/recognition of emotion and in empathy, incorporating an emotion-focused intervention (which has not been a focus of PMT) into traditional PMT should enhance outcomes for these children. Consistent with the aims of the R34 mechanism, the primary goal of this application is to develop and test the feasibility of a brief emotion-coaching (EC) intervention in combination with an evidence-based PMT program, Helping the Noncompliant Child (HNC; Forehand & McMahon, 1981; McMahon & Forehand, 2003), for use with clinic-referred children with ODD who have limited prosocial emotions. The Specific Aims are to: 1) develop and refine an empirically based combined HNC-EC parenting intervention to reduce CP in children with ODD and limited prosocial emotions; and 2) assess the viability of a later clinical trial by a) pilot testing the newly developed HNC-EC intervention compared to HNC alone with mothers and their 3-7 year-old children who have been referred for treatment of significant levels of oppositional behavior (and who also have limited prosocial emotions) in a community mental health center setting, and b) establishing the treatment feasibility (family and therapist-level feasibility, treatment fidelity, participant satisfaction) and research feasibility of the HNC-EC intervention compared to HNC alone. While pilot studies should not be used to estimate effect sizes, (Kraemer et al., 2006; Sherrill et al., 2009), we will explore trends in the data to facilitate consideration of possible designs for later statistical modeling in a larger trial. Promising findings would form the basis of a research proposal for a randomized clinical outcome study comparing HNC alone and in combination with an EC intervention for children with ODD and limited prosocial emotions. Should this combined intervention (which is focused on improving outcomes in this hard-to-treat population) prove to be effective, it will be one of the first interventions targeting known developmental mechanisms related to limited prosocial emotions in children. Given the increased likelihood that children with an early onset of CP and limited prosocial emotions are at increased likelihood of multiple negative outcomes extending into adulthood, at extraordinary social and economic cost, improving response rates to PMT (which is a low-cost, low-restrictiveness intervention) will have substantial public health impact.