Childhood conduct problems - otago.ac.nz · adolescents with significant levels of ... specificenes g in the development of antisocial behaviour and ... play an important role in

Chapter 4: Childhood Conduct Problems

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Chapter 4

Childhood conduct problems

David FergussonChristchurch Health and Development Study, University of Otago, Christchurch

Joseph BodenChristchurch Health and Development Study, University of Otago, Christchurch

Harlene HayneDepartment of Psychology, University of Otago

Summary• Theseedsofmanyadolescentdifficultiesaresownveryearlyindevelopment.

• Forexample,conductproblemswhichfrequentlybegininearlychildhoodoftenextendover the life course. Conduct problems in childhood andadolescence are relativelycommonandmayafflictupto10%ofthepopulation.

• Conductproblemsinchildhood(andadolescence),haveprofoundconsequencesforlater development including antisocial behaviour, crime, mental health difficulties,suicidalbehaviours,substanceabuse,teenagepregnancy, inter-partnerviolenceandphysicalhealth.

• A number of evidence-based interventions have been shown to be effective in theprevention, treatment and management of childhood conduct problems. Currentmoves to introducesuchprogrammes intoNewZealandshouldbeencouragedandstrengthened.

• Otherprogrammesinthisareahaveeithernotbeenevaluatedorhavebeenfoundtobeoflimitedefficacy,orevenharmful.

• Major issues that remain tobeaddressedareworkforceenhancement,programmeevaluationresources,anddevelopmentofTeAoMāoriprogrammes.

1. IntroductionTheaimofthischapteristoprovideabroadoverviewoftheaetiology,consequencesandtreatmentofconductproblemsduringdevelopmentwithaspecificfocusonbothNewZealandevidenceandthedevelopmentofNewZealand-basedpolicyandservices.


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2. What is the question?Therehasbeenlongstandingscientific,publicandpoliticalinterestaboutissuesrelatingtotheprevention,treatmentandmanagementofantisocialbehaviours inchildrenandadolescents.Typically,theseconcernshavefocusedonaminorityofyoungpeoplewhoarecharacterisedbyrecurrentaggressive,violent,oppositional,dishonestandantisocialbehaviours.The terminologyused todescribe theseyoungpeoplehasvariedbetweendisciplines. Inpsychiatryandclinicalpsychologythese individualsareusuallydescribedas having oppositional defiant disorder (ODD) or conduct disorder (CD) [1, 2].Withineducationalcirclestermssuchaschallengingbehaviourandemotionalandbehaviouraldisturbance(EBD)havebeenused[3]todescribethesameconstellationofbehaviours.Toaddressthesedifferencesinterminology,theNewZealandAdvisoryGrouponConductProblems(AGCP)hassuggestedtheuseoftheterm“conductproblems”whichtheydefineasfollows:

“Childhood conduct problems include a spectrum of antisocial, aggressive, dishonest, delinquent, defiant and disruptive behaviours. These behaviours may vary from none to severe, and may have the following consequences for the child/young person and those around him/her: stress, distress and concern to adult care givers and authority figures; threats to the physical safety of the young people involved and their peers; disruption of home, school or other environments; and involvement of the criminal justice system.” [4]

3. Why is it important for the transition to adolescence?It is widely recognised that conduct problems in childhood and in adolescence causedifficultiesandstressforyoungpeopleandforthoseindividualswhoareassociatedwiththemincludingparents,teachersandpeers[5].ThereisnowsubstantialevidencefromNewZealand’smajorlongitudinalstudiesthattheseproblemshavelongtermconsequencesthatextendintoadulthood.Specifically,boththeChristchurchHealthandDevelopmentStudy(CHDS)andtheDunedinMulti-disciplinaryHealthandDevelopmentStudy(DMHDS)havefollowedbirthcohortsofabout1000childrenfromearlychildhooduptotheage30 and beyond. The findings of these studies havemade it possible to determine theextenttowhichconductproblemsinchildhoodandadolescenceareprecursorsoflongertermadverseoutcomes[6-12].Thesestudieshavedemonstratedthatyoungpeoplewithsignificantconductproblemsareatincreasedrisksof:

• later crime, arrest and imprisonment;

• substance use and abuse;

• mentalhealthproblemsincludingdepressionandanxiety;

• Suicidalthoughtsandattempts;

• teenagepregnancyandparenthood;

• inter-partnerviolence;

• impairedparentingbehaviours;

• poor physical health; and

• poordentalhealth.

Giventhisbodyofevidence,thereisnoothercommonlyoccurringchildhoodconditionthat has such far reaching and pervasive consequences for later health, developmentandsocialadjustment.Forthisreason,socialinvestmentsintotheprevention,treatment


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andmanagementofconductproblemsshouldbeamatterofthehighestpriorityintheplanningofservicesforchildrenandadolescents.

4. What is the scale of the problem?While estimatesof the fractionof childrenwith clinically significant conduct problemshavevariedmost studies set theprevalenceof theseproblems in the regionof5-10%[3,13-15]. Ifweusethe lower limitofthisrangetoestimateprevalence,withinthe3-to17-year-oldNewZealandpopulation, therewill be inexcessof40,000 childrenandadolescentswithsignificantlevelsofconductproblems.Thosemostlikelytodisplaytheseproblemsare:male,Māori,andyoungpeoplefromsociallydisadvantagedbackgroundswhicharecharacterisedbylowsocioeconomicstatus,violence,parentalcriminalityandsubstanceabuse,andinconsistentorharshparentingpractices[3,16].

5. What research tells us about causative factorsThereisalargeandevergrowingliteratureonthefactorsthatplacechildrenandyoungpeopleatriskofdevelopingsignificantlevelsofchildhoodconductproblemsaswellasthefactorsthatmayactinaprotectiverole[17-21].Whatemergesmoststronglyfromthisbodyofevidenceisthatthereisnosinglefactororsetoffactorsthatexplainswhysomeyoungpeopledevelopsignificantconductproblemswhileothersdonot.Rather,theevidencesuggestsconductproblemsaretheendpointofanaccumulationoffactorsthatcombine toencourageandsustain thedevelopmentofantisocialbehaviours.Amongstthebetterdocumentedfindingsarethefollowing.

5.1 Genetic factorsThepredominanceofmaleswithconductproblemsclearlyhintsatthepossibilitythatthebiologicalandgeneticfactorsmayplayanimportantroleinthedevelopmentofconductproblems. There is, in fact, strong evidence to suggest the role of underlying geneticfactors fromresearchusing twinandadoptiondesignswhichhassuggestedthatupto40%ofthevariabilityinantisocialbehavioursmaybegeneticinorigin[22].Morerecentlywiththedevelopmentofgenetictechnologyithasbecomepossibletoexaminetheroleofspecificgenesinthedevelopmentofantisocialbehaviourandthisresearchisbeginningtohighlighttheimportanceofgenexenvironmentinteractionsinwhichtheoutcomesthatyoungpeopleexperiencedependonboththeirgeneticbackgroundandtheenvironmenttowhichtheyareexposed[23,24].

5.2 Socio-economic factorsAnotherpervasivefindingintheresearchliteraturehasbeenthatratesofmanytypesofchildhoodproblems,includingchildhoodconductproblems,tendtobehigheramongstfamilies facing sources of social inequality and deprivation including poverty, welfaredependence,reducedlivingstandardsandrelatedfactors[25-30].Thesefindingshighlightthefactthatthegeneralsocio-economicmilieuwithinwhichchildrenareraisedhasfar-reachingconsequencesfortheirhealthydevelopment.

5.3 FamilyThere isasubstantialbodyofresearchwhichshowsthatthenatureandqualityofthechild’sfamilyenvironmentplaysanimportantroleinthedevelopmentandmaintenance


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ofconductproblems[26,31-38].Inparticular,childrenrearedinhomescharacterisedbymultiplesourcesofadversityincludingfamilyviolence,childabuse,inconsistentdisciplinepractices,multiplechangesofparentsandsimilarfactorsemergeasbeingatsubstantiallyincreasedrisksofdevelopingsignificantlevelsofconductproblems.

5.4 SchoolsAsRutterhaspointedout,childrenspendintheregionof15,000hoursatschool[39].Giventhis,itisnotsurprisingtofindthatthenatureandqualityoftheschoolenvironmentplayan importantrole inshapingchildren’sbehaviour.Growingevidencesuggeststhatschoolsthatofferconsistent,nonpunitiveandsupportiveenvironmentsreducerisksofconductproblems[40-42].

5.5 PeersThenatureandqualityoftheyoungperson’speerrelationshipsalsoplayan importantrole in shapingbehaviour;peer influence isparticularly importantduringadolescence.Affiliation with anti-social and substance-using peers leads to the onset of conductproblemsinyoungpeoplewithapreviouslyunproblematiclifehistory[26,43-46].TheroleofpeersinthedevelopmentofconductproblemsalsounderliesanimportantdistinctiondrawnbyMoffittonthebasisofherwork[29,47,48]withtheDunedinMultidisciplinaryHealthandDevelopmentStudy(DMHDS).Inparticular,Moffittsuggestedthatthereweretwodistincttrajectoriesbywhichconductproblemsdevelop.Thefirstisthelifecoursepersistentpathway.Youngpeoplefollowingthispathwayshowsignsofconductdisorderveryearly indevelopmentwhichpersistover the lifecourse.Moffittsuggests that thispathway includes young people who have neuro-psychological deficits and who areexposedtodisadvantagedordysfunctionalchildhoodenvironments.Thesecondpathwayistheadolescent-limitedpathway.Youngpeoplefollowingthispathwaytypicallydonotshowsignificantconductproblemsuntiladolescence;theydevelopconductproblemsbyimitatingthebehavioursofantisocialpeers.

5.6 OverviewWhat emerges from this large body of research is that the development of childhoodconductproblems is theendpointofa largenumberofbiological, sociological, familyandpersonalfactorswhichactcumulativelytoaffecttheyoungperson’sdevelopmentaltrajectoryandplaceasignificantminorityof individualsatriskofdevelopingantisocialbehaviour patterns. Conversely, what protects young people from developing theseproblemsisexposuretosupportiveandnurturingenvironmentsathome,atschool,andwithinothersocialcontexts.

6. What research tells us about prevention programmes that workOverthelasttwodecadestherehavebeenrapidadvancesinthedevelopmentofeffectiveprogrammesaimedattheprevention,treatmentandmanagementofconductproblems.Theseadvanceshavebeenpossibleasaresultofanincreasingnumberofresearchstudiesthathaveexaminedtreatmentsforconductproblemsusingrandomisedcontrolledtrials(RCTs).Typicallyinsuchtrials,youngpeoplewithconductproblemsaredividedintotwogroupsatrandom.Onegroup,(theexperimentalgroup)receivesthenewtreatmentorprogrammewhereastheothergroup,(thecontrolgroup) isprovidedwiththeusualor


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existingtreatment.ProvidingthatRCTsarewellconducted,theyprovidestrong,butnotinfallible,evidenceoftheeffectivenessofinterventions[49,50].

There is a large literatureon the risk andprotective factors associatedwith childhoodconduct problems. One of themost robust and pervasive findings in the literature isthatchildrenwhodevelopconductproblemsfrequentlycomefromhomeenvironmentscharacterisedbymultiple sourcesof social, economic, familyand relateddisadvantage[26,31,38,46,51].Thesefindingshavemotivatedeffortstointervenewithsocalled‘atrisk’ populations veryearly indevelopment tomitigate theeffectsof economic, socialandfamilydisadvantageandimproveoutcomesforchildren.Typically,theseprogrammesaretargetedataddressingmultipleissuesrelatingtohealth,development,parentingandchildbehaviourduringthepreschoolyears.Abriefreviewoffindingsfromthisresearchapproachisgivenbelow.

6.1 Home visiting programmesBoth within New Zealand and internationally, large investments have been made inthedevelopment of intensive home visitingprogrammes for families facing stress anddifficulties [52-60]. These programmes usually start around or before birth and aredeliveredbyhomevisitorswhoaimtoprovideadvice,assistance,supportandmentorshiptofamilies.Programmesmaylastupto5yearsandaimtoaddressawiderangeoffamilyissues includingparentingand childbehaviour.Manyof theseprogrammeshavebeenevaluatedusingrandomisedcontrolledtrials.Reviewsofthisevidencesuggesttheresultsofmanyhome-basedinterventionshavebeendisappointingandfewpositiveeffectshavebeenfound[52,61,62].Thereare,however,atleasttwoexceptionstothistrend.Thefirst,andmost impressive, is theNurseFamilyPartnership (NFP)developedbyOldsandhiscolleagues[61].TheNFPprovidesaprogrammeofintensivehomevisitationdeliveredbynursestodisadvantagedyoungmothers.Thechildrenwhosemothersparticipatedintheprogrammewerefolloweduptotheageof15.Incomparisontoarandomcontrolgroup,theadolescents in those familieswhohadreceivedNFPhad fewerarrests,convictionsandprobationviolationssuggestingthatNFPinterventionsmitigaterisksassociatedwithsevereantisocialbehavioursinadolescencethatoftenemergefromconductproblemsinchildhood[63].

ThesecondstudytoshowpositivebenefitsforchildbehaviourwastheNewZealand-basedEarlyStartprogramme.Thechildreninthisprogrammehaveonlybeenevaluateduptotheageof3years,butfindingsuptothatageindicatethatchildrenenrolledinEarlyStarthadfewerproblembehavioursatage3years[52].Thegeneralconclusionsthatemergefromtheliteratureonhomevisitationisthatwell-designedhomevisitationcanreducerates of conduct problemsbut to be effective theseprogrammesneed to be carefullyimplementedandrequirerigorousevaluation[63].Themostsuccessfulprogrammesaredesigned to enhance children’s emotional, regulatory, and social development aswellas increase their numeracy and literacy skills. Childrenwhosehomeenvironments arepoororarecharacterisedbyotherrisk factors,gain themost fromthesecentre-basedprogrammes.

6.2 Centre-based programmesCentre-basedprogrammesprovideanalternativetohome-basedprogrammes.Intheseprogrammes,childrenfromat-riskbackgroundsattendpre-schooleducationcentresthatprovide systematicprogrammes aimed at reducing risks of behavioural difficulties andincreasingacademiccompetence. It is importanttonotethatsuchprogrammesshould


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notbeequatedwith theprovisionofpreschool education; theprogrammesdescribedbelowcontainspecificfeaturesaimedatmitigatingchildhooddisadvantages.

While formal evaluations have shown that these programmes have limited success inincreasingchildren’scognitiveabilitiesoverthelongterm,thereisgrowingevidencethattheymaymake strong contributions to thedevelopment of non cognitivebehaviouralskills[64].

Notable examples of successful centre-based programmes include the Abecedarianprogramme [65, 66] and the Perry Preschool Project [67]. As with home visitation,randomised trials suggest that well-designed, centre-based programmes can reducerisksoflongertermconductproblems.ThisevidencehasbeenrecentlyreviewedbytheeconomistJamesHeckmanwhoconcludes:

“Early interventions targeted toward disadvantaged children have much higher returns than later interventions such as reduced pupil teacher ratios, public job training, convict rehabilitation, tuition subsidies or expenditure on police.” (p.1902)[64]

Becausemultipleriskfactorscontributetoconductproblemsinchildhood,earlychildhoodcentre-basedprogrammesthat reducemultiple risksaremoresuccessful inpreventingchronicdelinquencyandinmaximisinglong-termsuccessthanarethosethattargetonlya single risk factor. Theprogrammes thatdemonstrate long-termeffectson crimeandantisocialbehaviourtendtobethosethatcombinecentre-basedprogrammesforchildrenwithfamilysupportservices.

6.3 Community-based programmesAfurtherpreventativeapproachhasbeenthroughthedevelopmentofcommunity-basedprogrammesthatattempttoprovideservices,resourcesandsupportsforat-riskfamiliesandchildren.Twoexamplesofeffectivecommunity-basedprogrammesaretheChicagoChildParentCentres[68,69]andCommunitiesThatCare[70].

7. What research tells us about treatment and management programmes that work

Although the prevention programmes outlined above provide useful approaches forreducing the risks of conduct problems for children from ‘at risk’ environments, evenwith suchprogrammesanumberof childrenwill goon todevelop significant conductproblems. There is nowa large, impressive andever growingbodyof literature aboutthetypesofprogrammesthataremosteffectiveforthetreatmentandmanagementofconductproblems.Theseinterventionsspanbothhomeandschoolandaresuitablefordifferentages,whilesharinganumberofcommonfeatures:

• all programmes use non-punitive problem solving approaches that attempt toaddressthesourcesofthechildren’sproblembehaviours;

• allarefoundedinaclearlyarticulatedtheoreticalframeworkregardingtheaetiologyof conduct problems;

• allprogrammesaremanualisedmakingitpossibletotransfertheprogrammetoanewcontext;and

• theevaluationofallprogrammeshasbeenfoundedonapreventionsciencemodelandtheuseofrandomisedcontrolledtrials(seeChapterXXforfurtherdiscussion).


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7.1 Parent Behaviour Management TrainingOne of themost successful approaches to addressing conduct problems in early andmiddlechildhoodhasbeenParentBehaviourManagementTrainingprogrammes.Theseprogrammeshavebeenbasedontwoareasofresearch.First,maladaptiveparent-childinteractions, particularly in relation to discipline practices, have been shown to fosterand to sustain conduct problems among children. Second, social learning techniques,relying heavily on principles of operant conditioning, have been extremely useful inaltering parent and child behaviour. Typically Parent Behaviour Management Traininginvolvestherapistsorfacilitatorsteachingparentsarangeofskillsforthemanagementofbehaviour.Theseskillsinclude:carefullyobservingandrecordingchildbehaviour;theuseofpositivereinforcement,theavoidanceofphysicalpunishment;theuseoftimeout,lossofprivileges;andrelatedskills.Parentmanagementtrainingmaybeprovidedinbothagroupcontextandaone-on-onebasis[3,71-74].

There isnowa rangeofmanualised,well validatedandwidelyusedprogrammes thatemploytheseprinciples.Theprogrammesinclude:

• theTripleP(PositiveParentingProgrammes)[75,76];

• theIncredibleYearsProgrammes[77,78];

• ParentManagementTrainingOregon[79,80];and

• ParentChildInteractionTraining[81,82].

Theseprogrammesofferaseriesofoptionsfordeliveringparentbehaviourmanagementtrainingwhichrangefromuniversalprogrammesdirectedatallparentstohighlyintensiveprogrammesforchildrenwithseverebehaviourdisturbance.Theweightoftheevidencesuggeststhattheseprogrammesaremostsuccessfulwithchildreninthe3–7yearsagerangewheretreatmentmayreduceratesofconductproblemsbyupto80%[3,4,83]withprogrammeeffectivenessdecliningwithincreasingageofthechild[3,4,84].

7.2 Teacher Behaviour Management TrainingParallel to research into Parent Behaviour Management Training there has also beensimilar research into classroom-based Teacher Behaviour Management Training.However,theextentofthisresearchhasbeenfarmorelimitedthanresearchintoParentBehaviourManagementtrainingandtherearerelativefewwellvalidatedandmanualisedprogrammesavailable.TeacherBehaviourManagementTrainingprogrammesinclude:

• theIncredibleYearsTeacherProgramme[78];and

• theCLASSandRECESSprogrammesdevelopedbytheOregonSocialLearningCentre[85-87].

7.3 School wide interventionsThereisincreasingevidencetosuggestthatthenatureandqualityofschoolenvironmentsplayanimportantroleinthepreventionandmanagementofchildhoodconductproblems.This research has led to the development and validation of the SchoolWide PositiveBehaviour Support (SWPBS) programme. SWPBS is a decisionmaking framework thatguidesselection,integration,andimplementationofthebestevidence-basedacademicandbehaviouralpracticesforimprovingimportantacademicandbehaviouroutcomesforallstudents[88,89].

SWPBSemphasisesfourintegratedelements:(a)datafordecisionmaking,(b)measurableoutcomessupportedandevaluatedbydata,(c)practiceswithevidencethattheseoutcomes


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areachievable,and (d) systems thatefficientlyandeffectively support implementationof thesepractices.Theprogramme is suitable for implementation inbothprimaryandsecondaryschoolsettings[83,84].

7.4 Multimodal programmesAs children grow older and their conduct problems become more entrenched, theeffectivenessoftheprogrammesdescribedabovetendstodecline[4,83,84].Recognitionof this fact has led to the development ofmultimodal interventionwhich is aimed attreatingandmanagingconductproblemsacrossarangeofsettingsinvolvingfamilies,theschool,teachersandpeers.Theseprogrammesaremostsuitedforadolescentpopulationsand include:

• MultisystemicTherapy[90,91];

• FunctionalFamilyTherapy[92,93];

• CopingPower[94];

• StopNowandPlan[95];and

• LinkingInterestsofFamiliesandTeachers[96].

All of these programmes are manualised and have been validated by randomisedcontrolledtrials.

7.5 Residential/out of home interventionsFinally,somechildrenandyoungpeoplewithconductproblemsmayberemovedfromtheir home either because of conduct problems or because of care and protectionissues.While conventional residential and foster care has been found to have limitedeffectivenessinaddressingtheissueofconductproblems,therearetwospecialisedoutofhomeinterventionsthathavebeenfoundtobeeffective.

Thefirst isMultidimensional TreatmentFosterCare (MTFC) [3,97]. In thisprogrammechildrenwithseverebehaviouraldifficultiesareplacedwithspeciallytrainedfosterparentswho are provided with ongoing support by a team of trained therapists. Placementstypicallylastfor6-9months.Theprogrammeinvolvesastructuredbehaviourmanagementsystemforthechildsupplementedwithfamilytherapyandsupportforthechild’sbirthfamily. Teaching FamilyHomes also provide out of home treatments for childrenwithsevereconductproblems–inthesehomes,uptosixchildrenareplacedwithspeciallytrainedfosterparentswhoactastherapistswhoteachthechildrenarangeofbehaviouralskills,includingsocialskills,problemsolving,emotionalcontrolandrelatedskills[98].

8. Interventions for which evidence of efficacy is limited or lackingWhile there is growing evidence on the types of programme that are effective in thetreatmentandmanagementofchildhoodconductproblems,ithasalsobecomeapparentthatmanyprogrammesinthisareahaveeithernotbeenevaluatedorhavebeenfoundtobeoflimitedefficacy.Amongsttheprogrammesfoundtobeoflimitedefficacyare:

• wildernessprogrammes[99];

• bootcampsandmilitarystyletraining[100,101];

• mentoringprogrammes[102,103];

• restorativejustice[104];and

• ScaredStraightprogrammes[105,106].


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Forsomeoftheseprogrammes(wildernesstraining,militarystyletraining,mentoringandrestorativejustice)it ispossibletofindexamplesofapparentlysuccessfulprogrammes.However,what is not clear are the features that distinguish unsuccessful programmesfrom successful programmes. For other programmes, such as Scared Straight, thereis evidence suggesting that the programmesmay have harmful effects. Research intoprogrammeswithlimitedevidenceofefficacyhastwoimportantmessagesforthechoiceandimplementationofprogrammes.First,thisresearchsuggeststhatitisimportantthatinvestments intopoliciesarebasedonwell foundedevidenceprovidedbyrandomisedcontrolledtrials.Secondly,variationsintheoutcomesofapparentlysimilarprogrammeshighlightstheimportanceofsubjectingprogrammestothoroughevaluationwhentheyareinstalledinanewandculturallydifferentcontextsuchasNewZealand[4].

9. Where is policy/intervention currently focused?Themajor issues posed by this body of research and evidence are that of developingpolicies,strategiesandservicestotranslatethisevidencetoeffectiveNewZealand-basedpolicyandpractice.ApromisingstarthasbeenmadeinsomesectorsofGovernment:

• ThePositiveBehavioursforLearning(PB4L)strategydevelopedbytheMinistryofEducationhasmadeastepintherightdirectionbysettingoutaplanforthreeoftheevidence-basedprogrammesnotedinthereviewabove[107].Theseprogrammesare the Incredible Years Basic Parent Programme, the Incredible Years TeacherProgrammeandSchoolWideBehaviourSupport.

• TheDriversofCrimeStrategy [108]also includesproposals to includeaprimarycare-basedversionoftheTriplePprogramme.

• TheMinistryofSocialDevelopmentinpartnershipwiththeMinistriesofEducationand Health has invested in the development of an evaluation of the IncredibleYears Parentprogrammewith further evaluationof the Incredible Years TeacherprogrammeandSchoolWideBehaviourSupportbeingplanned[109].

10. Implications for future policyWhile there is increasing investment inevidence-basedprogrammes for the treatmentandmanagement of conduct problems inNew Zealand, there are a number ofmajorissuesthatstillneedtobeaddressed.Theseincludethefollowing.

10.1 Implications for the New Zealand Youth Justice SystemThe prevention, treatment and management of conduct problems in childhood andadolescence has important implications for the New Zealand Youth Justice System.In particular, childrenwith early-onset, life-coursepersistent conduct problemshave ahighriskofcomingtotheattentionofJusticesystemandwillmakeupthemajorityofthoseindividualswhogoontobecomerepeatoffenders.Providingtheearlyinterventionprogrammesdescribedaboveoffersameansof reducing thenumberofyoungpeoplewhodeveloplife-coursepersistentconductproblems.Further,anumberofprogrammesreviewed previously offer promising treatment approaches for addressing adolescentconductproblemsandarewell suited tobe incorporated into theNewZealandYouthJustice System. These programmes include: Functional Family Therapy,Multi-systemicTherapy,TreatmentFosterCareandTeachingFamilyHomes.Allof these interventionshave been evaluated using randomised controlled trials and have been found to be


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effective in reducing ratesofantisocialbehaviouramongstadolescentswithsignificantconductproblems.ThereisastrongcaseforextendingcurrentYouthJusticeprovisionstotrialtheeffectivenessofthesemethodsinaNewZealandcontext.

10.2 Workforce issuesManyoftheprogrammesdescribedinthisrequiretrainedprofessionalstaffincludingchildpsychologists,childpsychiatrists,trainedtherapistsandteacherstooverseesuperviseanddeliverevidence-basedprogrammes.Thesestaffarecurrentlyinshortsupplyandthereisanurgentneedtoinvestinworkforcedevelopment[4].

10.3 Programme evaluation resourcesTherehavebeenongoingdebatesabouttheextenttowhichevidence-basedprogrammesdevelopedoutsideofNewZealandcanbetransplantedintoaNewZealandcontextandstill remain effective. To address these concerns it is important that programmes arethoroughlyevaluatedinaNewZealandcontextbeforebeingwidelyimplemented.AtthepresenttimetherearelimitedresearchresourcesinsideofandoutsideofGovernment.There is a strong case for increasing investments into research and development stafftoensurethat investmentsmade intoNewZealand-basedprogrammesareadequatelyevaluated[4,83].AsshownintheAppendix,researchintheUSandelsewherehasshownthat the return from well-implemented and well-evaluated prevention, intervention,andtreatmentprogrammesforconductproblemsisoftenverygood,withprogrammesreturningseveraltimestheircostsasaresultofreducedratesofcrimeimprisonmentandassociatedcosts.

10.4 Development of Te Ao Māori programmesAs noted earlier, rates of conduct problems in Māori are higher than for non Māori[4].Given that conduct problems are an important precursor to awide rangeof lateradverseoutcomes,itisamatterofhighsocialandpolicyimportancethatthisinequalityis addressed. One important route for delivering culturally acceptable and culturallyappropriateprogrammes forMāori is through increased investmentand supportof TeAoMāori(byMāoriforMāori)initiativesinthisarea[4,83].TheseissuesarediscussedatgreaterlengthinChaptersXXandYY.

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57

Appendix 1: Summary of evidence on effective treatmentsThereviewinthemainchapterprovidesanoverviewoftheevidenceregardingeffectiveinterventionstoaddressconductproblems inyoungpeople.Thisreviewisbasedupona largeandgrowing literaturethathas identifiedeffectivestrategies, interventionsandtreatmentstoreducetheprevalenceofconductproblemsamongstyoungpeople.Table4.1 attempts toprovideabrief andaccessible summaryof thisbodyof evidence. Theformat of the Table has been adapted from the Table presented in a companion chapter on alcohol in adolescence (Chapter XX) and summarises the evidence on a series ofapproachestoaddressconductproblems.

TheTableisdividedintopreventiveprogrammeswhichaimtoreduceratesofantisocialbehavioursbeforetheseoccurandtreatmentprogrammesaimedatprovidingassistancetochildrenandyoungpeoplewithsignificantconductproblems.Eachareaofinterventionisclassifiedintermsof:

(a)overalleffectiveness

(b) breadth of research support

(c)crossnationaltesting

Overall effectiveness is scored as:

0 Evidenceindicatesalackofeffectiveness

+ Evidenceforlimitedeffectiveness

++ Evidenceformoderateeffectiveness

+++ Evidenceforahighdegreeofeffectiveness

? Nocontrolledstudieshavebeenundertakenorthereisinsufficientevidenceuponwhichtomakeajudgement

Breadth of research support is scored as:

0 Nostudiesofeffectivenesshavebeenundertaken

+ Oneortwowell-designedeffectivenessstudiescompleted

++ Several effectiveness studies have been completed, sometimes in differentcountries,butnointegrativereviewswereavailable

+++ Enough studies of effectiveness have been completed to permit integrativeliteraturereviewsormeta-analyses

Cross-national testing is scored as:

0 Thestrategyhasbeenstudiedinonlyonecountry

+ Thestrategyhasbeenstudiedinatleasttwocountries

++ Thestrategyhasbeenstudiedinseveralcountries

+++ Thestrategyhasbeenstudiedinmanycountries

Inaddition,thetableprovidesnarrativecommentsonspecificinterventions.Table4.1maybeusedtoclarifyandelaborateonthegeneralrecommendationsmadeinthechapter.


58

Tabl

e 4.

1. S

umm

ary

of e

ffec

tive

pro

gram

mes

for

the

prev

enti

on a

nd tr

eatm

ent o

f con

duct

pro

blem

s

Stra

tegy

or i

nter

venti

onEff

ectiv

enes

sBr

eadt

h of

re

sear

ch

supp

ort

Cros

s-

natio

nal

testi

ng

Com

men

ts

Prev

enti

on p

rogr

amm

es

Hom

evisitin

g(e.g.N

urseFam

ily

Part

ners

hip)

++++

+++

Thereisevide

ncethatsom

eho

mevisitin

gprog

rammes,n

otab

lyth

eNurse

FamilyPartnershipcan

beeff

ectiv

einre

ducing

anti

socialbeh

aviours.How

ever,

man

yprog

rammesin

thisareaha

vebee

nshow

ntobeineff

ectiv

e.

Centre-based

program

mes(e

.g.

Abe

ceda

rian

, Per

ry p

resc

hool

)++

+++

+Th

ereisgoo

deviden

cefrom

US-ba

sedprog

rammesto

sug

gestth

atcen

tre-

basedprog

rammesta

rgeted

atd

isad

vantaged

pre-schoo

lersm

ayhavelong

term

be

nefitsinre

ducing

lateran

tisocialb

ehaviours.

Commun

ity-based

program

mes(e

.g.

Commun

itiesTha

tCare;Chicago

Paren

tCh

ild C

entr

es)

++++

++Th

ereisgrowinginternati

onalevide

ncetosug

gestth

atcom

mun

itylevel

prog

rammesta

rgeted

atd

isad

vantaged

com

mun

itiesand

familiesm

ayhave

positiv

ebe

nefitsinre

ducing

anti

socialbeh

avioursinyou

ngpeo

ple.

Trea

tmen

t pr

ogra

mm

es

ParentBeh

aviourM

anagem

ent

Training

(e.g.IncredibleYears,TripleP,

ParentM

anagem

entO

rego

n,Paren

tCh

ildIn

teracti

onTraining)

+++

+++

+++

ParentBeh

aviourM

anagem

entT

raining(PBM

T)isth

emoste

ffecti

veand

well

supp

ortedap

proa

chto

add

ressingchild

hood

con

ductproblem

san

dha

sbe

en

supp

ortedinnum

erou

scontrolledtrials.The

ben

efitsofthe

seprogram

mesare

greatestfo

ryoun

g(<8yea

rs)childrenan

dde

clinewith

increa

sing

age.

Teache

rBe

haviou

rMan

agem

ent

Training

(e.g.IncredibleYearsTeache

rProg

ramme)

+++

+Th

eeviden

cefo

rtheeff

ectiv

enessofTea

cherBeh

aviourM

anagem

entT

raining

(TBM

T)isfa

rwea

kerthan

forPB

MT.How

ever,the

reisgrowingeviden

cefrom

controlledtrialsand

singlesubjectstudiesth

atTBM

Tiseffe

ctivein

redu

cing

rates

ofanti

socialbeh

avioursinaclassroom

setti

ng.

Scho

olwideprog

rammes(e

.g.

Scho

olW

ideBe

haviou

rSu

pport)

+++

++++

Thereisgrowingeviden

ceth

atSchoo

lWideBe

haviou

rSu

pportiseff

ectiv

ein

bothre

ducing

anti

socialbeh

avioursinschoo

lsand

providing

treatm

entfor

child

renwith

con

ductproblem

s.

Multi-mod

alprogram

mes[e

.g.

MultiSystem

icThe

rapy(M

ST);

Functio

nalFam

ilyThe

rapy(F

FT)]

+++

++++

Thereissub

stan

tialevide

ncethatm

ulti-mod

alprogram

messuchasM

STand

FFTareeff

ectiv

einadd

ressingthene

edsofado

lescen

tswith

con

ductproblem

s.

How

ever,resultsfo

rMSThavebe

envariable.

Outofh

omeprog

rammes[e

.g.M

ulti-

Dim

ension

alTreatmen

tFosterCa

re

(MTFC);Tea

chingFamilyHom

es(T

FH)]

+++

++++

Thereisgrowingeviden

ceto

sug

gestprogram

messuchasM

TCorTFHare

effectiv

einre

ducing

ratesofanti

socialbeh

aviourin

childrenan

dyoun

gpe

ople

with

significan

tcon

ductproblem

s.


59

Appendix 2: Cost benefits of effective treatments for conduct problemsThereisextensiveevidencetosuggestthattheprogrammessummarisedinTable4.1arehighlycosteffective.Asummaryofanumberofillustrationsofthecosteffectivenessofvariousapproachesisgivenbelow.

• Home visiting:TheRandCorporationconductedacostbenefitanalysisoftheNurseFamily Partnership programme. This evaluation concluded that the programmereturnedUS$4foreverydollar invested,with20%ofthesesavingscomingfromreduced costs of criminal justice for the offspring of families enrolled in theprogrammes[110].

• Centre-based programme: InananalysisofthecostbenefitsofthebenefitsofthePerryPreschool Programme,CunhaandHeckmanestimate that theprogrammereturnedoverUS$9foreverydollarspent,with72%ofthesesavingscomingfromreducedcostsoffuturecrime[111].

• Community-based programmes:CunhaandHeckmanestimatedthattheChicagoChild Parent Centres produced a return of US$ 7.77 for every dollar investedwith 25% of these savings coming from reduced costs of future crime [111]. Acost-effectiveness study revealed that a ten-year investment of $US 30 millionin prevention programs through the Pennsylvania Commission on Crime andDelinquency (PCCD) returnedovera ten-foldbenefitwithanestimated$US315million gained through reduced corrections costs, welfare and social servicesburden, drug andmental health treatment, and increased employment and taxrevenue [112]. Thepreventionprogram investmentwasassisted inPennsylvaniathroughtheCommunitiesThatCareframework.

• Parent Behavior Management Training:InareviewofthecostsoftheIncredibleYearsprogrammeinWales,Scott[71]concludedthatthelongertermreturnfromthisprogrammewaslikelytobe10timeshigherthanthecostoftheprogramme.

• Teacher Classroom Management Training: No cost benefit estimates of teacherclassroom management training have been reported. This reflects the limitedresearchevidenceinthisarea.

• School Wide Behaviour Support:Noevaluationof thecostbenefitofSWBShasbeenfound.However,Blonigenetal.provideadetailedaccountofthecostsofSWBSandoutlinetheissuestobeaddressedinconductingafullcostbenefitanalysis[88].

• Multi modal programmes: The Blueprints for Violence Prevention Group hasestimated that there is a US$ 8.38 return from every dollar invested in Multi-Systemic Therapy and a US$ 6.85 return from investments made in FunctionalFamilyTherapy[93,113].

• Out of home programmes:TheBlueprintsforViolencePreventionGroupestimatethat there is aUS$ 14.07 return fromevery dollar invested inMultidimensionalTreatmentFosterCare[93,113].

Alloftheseanalysesmake itclearthat investment inwell-validated,well-implementedpreventionand treatmentprogrammes for conductdisorder is likely tobehighly cost-effectivewiththereturns fromtheseprogrammesbeingseveraltimesthecostsof theinterventions.However,inappraisingthisliteraturethreepointsneedtobeborneinmind.


60

First, all of the cost benefit analyses reviewed have been conducted outside of NewZealandandthereisnoguaranteethatcost-enefitratiosreportedwillapplyintheNewZealandcontext.

Second, the cost-benefit estimates reported assume that the programmes describedarewell implemented and effective. Investments in ineffectiveor poorly implementedprogrammesarelikelytoproducenegativereturns.

Finally,manyof thecostbenefitestimates relyonmeasuresof latercrimeandsimilaroutcomes.Thisimpliesthatthebenefitsofsuchprogrammeswilloftenoccurmanyyearsinthefuturewhilethecostsareincurredinthepresent.Thesefeatureshighlighttheneedfora longterminvestmentstrategyinwhichtoday’sdollarsare investedforthefuturewell-beingofyoungNewZealanders.Thereisauniversalconsensusintheliteratureonthis topic that suchastrategy is likely tobehighlycost-effective,providing investmentismadeinwell-foundedandwell-implementedevidence-basedprogrammes[110,111,114-116].

Childhood conduct problems - otago.ac.nz · adolescents with significant levels of ... specificenes g in the development of antisocial behaviour and ... play an important role in

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