Research: children with antisocial personality disorders

THE RESEARCH

Title: Selective Review of Interventions for Children at Risk of Antisocial Personality Disorder. This international study was commissioned by the Department of Health and the prime minister’s strategy unit in 2006.

Study authors: David Utting, Helen Monteiro and Deborah Ghate.

Publisher: The Policy Research Bureau, 2007 (ISBN 978-0-9555313-0-9).

OBJECTIVES

The work focuses on interventions where there is robust evidence from published reviews including evidence from randomised controlled trials. It aims to establish:

● What is known about effectiveness.
● The strength of the evidence.
● The characteristics of the children and families for whom the interventions have demonstrated their effectiveness.
● The settings – health, social care, geography, social and cultural factors – where these interventions have been used.

The interventions chosen were:

● Two parenting programmes, The Incredible Years and Triple P.
● A home-visiting programme called Nurse-Family Partnership.
● Three further interventions designed for the families of particularly challenging children and young people: multi-systemic therapy, multi-dimensional foster care, and functional family therapy.

In addition to assessing effectiveness, the review also included some cost-benefit analysis as a guide to potential purchasers and providers of these programmes.

The authors begin with a survey of the risk and protective factors that lead children and young people either down the pathways that lead to persistent and intractable problems in adulthood or, alternatively, have the potential to steer them away from such a costly future – for them and for us.

The risk factors are organised under the headings of individual, family, school and community, in what might be called an ecological approach. Protective factors identified are: being female, resilience, self-efficacy and outgoing temperament, social bonding, adults setting standards of behaviour, opportunities for involvement, social and reasoning skills, and recognition and due praise.

Clearly some of these factors are less amenable to change than others – gender being the one that stands out, but this introduction sets the core questions: how can we intervene effectively to help young people move away from the “slippery slopes” on which some of them seem set at such an early age? and what are the positive features in their lives that we need to reinforce in order to strengthen their resistance?

FINDINGS

Some of the programmes reviewed here are familiar from previous reviews. The most obvious is The Incredible Years, a well-established parenting programme developed in the US by Webster-Stratton, but used and evaluated in other countries too. But the Triple P – the Positive Parenting Programme – is one that I did not know. This was developed in Australia and has yet to be properly evaluated in the UK – though there is work in England and Scotland reported here.

The core finding is: the six programmes are supported by considerable evidence of their effectiveness in achieving better outcomes for children and young people – especially those whose early-onset behavioural problems place them at risk for life-course persistent criminal involvement, antisocial behaviour and social exclusion.

Some of the evaluations are able to demonstrate the savings made when comparing the investment in these programmes with the cost of poor outcomes averted or reduced or with the costs of less effective interventions. And all show evidence of effectiveness across different cultural and ethnic groups.

There are key features required for effective interventions:

● A coherent and clearly articulated theoretical base.
● Professional, qualified/trained staff.
● High programme consistency – staff carry out the programmes as prescribed and do not allow them to become diluted.
● The capacity to be delivered in the natural environments of families and young people – they are not merely an impressive clinical showcase.
● The ability to be tailored to the needs of their core group.
● An approach that is based on partnership with families.
● A multi-dimensional model – they recognise the multi-factorial reality of people’s lives and try to respond accordingly.
● A tiered approach that is able to differentiate between different levels of difficulty.
● A commitment to go beyond the quick fix – the programmes and their evaluations are long enough to provide genuine impact.

Beside this good news there are various caveats. Not all the programmes have been rigorously evaluated in UK settings so there is a clear message about the need to test their effectiveness here. However successful a programme is, it will not work equally well with all young people and with all their families. A percentage will drop out of the programme and others will fail to respond. So we need to retain some common-sense caution. The authors also stress the need to target interventions appropriately.

This is where the tiered approach is particularly valuable. It makes no sense to provide the most sophisticated and costly programmes for those least at risk. The level of intervention needs to be geared to the level of risk.

There has been a lively debate for some years about the early identification of those at most risk of persistent behaviour problems and the danger of false positives – that is, some of the children predicted to present life-course, persistent problems will turn out to do nothing of the sort. Equally there are others – the false negatives – who do not appear on the local radar as children but who come to notice in later years.

CONCLUSIONS

Preoccupation with the bad behaviour of young people can be traced back over thousands of years so the issue is scarcely novel. Some of our media continue to present young people in alarmist terms with yet more pleas for symbolic gestures that may please the public gallery but offer little prospect of changing young people’s behaviour.

What is evident from this research review is that we have the means of investing in methods of intervention that are more likely to help young people at identified risk of continuing on destructive – and self-destructive – paths.

What sense does it make to continue to spend money that has proved ineffective in the past? What would be really useful – and is not available here – is a service map of which of the six interventions are available where across the UK. This would require a regularly updated survey of child and adolescent mental health services, youth offending teams, and other community health and social care facilities.

Initially, this is likely to be a map with lots of gaps. But over time it could be developed into a tool for both practice and research. Practitioners could identify where effective programmes were being run and researchers could more easily compare the value of different programmes. The Incredible Years programme is probably the most widespread in the UK but I am not aware of any easy means of mapping it nationally or regionally.

John Randall is a post-adoption social worker with Families for Children, a voluntary adoption agency. He writes monthly reviews of newly published research articles for the Research in Practice Research and Policy update.

➔ The Policy Research Bureau that produced this report closed in March this year but the summary is available as a pdf

RESOURCES

● Brosnan R & Carr A (2000), “Adolescent Conduct Problems” in What Works with Children and Adolescents? A Critical Review of Psychological Interventions with Children, Adolescents and their Families, p131-154, Taylor and Francis/Routledge, ISBN 0415 23350 X

● Joughin C & Morley D (2007), “Conduct Disorder in Older Children and Young People: Research Messages for Practice Problems,” Research in Practice, ISBN 978-1-904984-14-6

● Rutter M, Giller H & Hagell A (1998), Antisocial Behaviour by Young People, Cambridge University Press, ISBN 0521646081

● Scott S et al (2001), “Financial Cost of Social Exclusion, Follow-Up Study of Anti-Social Children into Adulthood”, British Medical Journal, 323 (7306)

This article appeared in the 1 November issue under the headline “Disrupting the pattern”