Children with conduct problems - prevention and intervention
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Children with Conduct Problems: Prevention and
Intervention
Stephen ScottInstitute of Psychiatry, King’s College London
Suomi, 7 November 2014
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Conduct Disorders (ODD & CD)Early antisocial behaviour is hugely predictive of later poor function
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Age 7 Anti-social
Violent offending
Heavy drug use
Teen
Parent
No exams
On
benefits
Top 5% 35 20 20 52 33
0- 50% 3 5 4 6 9
Outcomes at age 25 by how antisocial aged 7(Fergusson et al 2005)
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Its not just a social problem…Its not just a social problem…
What is Risk DEATHDEATH when aged 46 if, aged 7-11, in top 25% vs lowest
25% of children with conduct problems?
Over double(Jokela et al, 2009)
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Oppositional & defiant
Blamed by parents
Disliked by siblings
Gets into fights
Rejected by peers
Low self esteem
Hard to control
Poor school achievements
Blames others
Stealing and truanting
Deviant peer group
Antisocial attitude
Career offender
Unemployed
Drug misuse
0
5
10
15
5 years 8 years 11 years 14 years 17 years
Escape
1/5
1/5
1/5
4/5
4/5
4/5
4/5
Continuity of anti-social behaviour from age 5 to 17. Source: Scott 2002
% of allchildren
No past antisocial behaviour
1/51/5
10% 10% 10% 10%
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Estimated costs in UK(Friedli & Parsonage 2007)
115,000
230,000
0
50,000
100,000
150,000
200,000
250,000
better half 50th to 95th Conduct
disorder
Mea
n Cos
t £
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9. What is the pathway to high public cost, A or B?
Early risk factors
Socioeconomic status
Male AReading ability High CostParenting by adulthood
B B
AntisocialBehaviour at 10
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Biological effects of parenting
• Sixfold rise in cortisol in adolescent rats stressed by eye puff who were separated from mother 3hrs a day for a week as infants (Meaney)
• Elevated CRP in adult humans exposed to harsher parenting as children (Danesi, 2009 Archives Gen Psychiatry)
• Emerging evidence of specific genes conferring sensitivity to parenting (not just vulnerability a la Caspi 2003 for MAOA)
• But will treatment reverse this? Fisher 2007
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0
0.20.40.6
0.81
wakeup midmorning bedtime
low daytime HPA activity
ug/d
l
0
0.2
0.4
0.6
0.8
1
wakeup mid morning bedtime
typical daytime HPA activity
ug/d
l
typical development
0
0.20.40.6
0.81
wakeup midmorning bedtime
chronically elevated daytime
HPA activity
ug/d
l
stress-induced ‘blunted’ patterns
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Brain in conduct disorderRubia, Scott, Taylor et al (2008). Am J Psychiatry
Sustained Attention
RewardCD < C, ADHD
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Child characteristics affect parenting, and may be genetically
determined Abuse commoner in irritable, premature babies Some child characteristics strongly genetically
determined Callous –unemotional traits within antisocial behaviour
(80% heritability vs 30% without; Viding et al 2009) ADHD Intellectual disability
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“Cold CD” - CU traits
Callous – unemotional style Lacking empathy Lacking guilt Unkind Predatory aggression
Still from LeRoy’s “The Bad Seed” (1956)
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Callous Unemotional Traits
At the core of psychopathy (Cleckley 1941; Hare) In psychopathy, also impulsiveness, narcissism
Distinguishable from autistic traits CU can understand emotions, but don’t react ASD can’t understand others’ feelings/views
Distinguishable from ADHD In psychopathy not restless, can concentrate
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Eye Gaze Hotspots
“Cold’ conduct problems
Healthy boys Hi CU boys
Dadds et al. (2008) J Amer Acad Child Adolesc Psych.
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Child-only interventions can improve conduct problems Anger mangement; Social skills training (eg
Webster-Stratton) Stimulant medication when there is comorbid
ADHD
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ThinkThink
Feel Do
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Individual intervention for conduct problems
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Clinical trial (Scott, Spender et al 2001, BMJ)
• 141 children age 3-7 referred to CAMHS
• severe, persistent antisocial behaviour (worst 1%)
• ‘Incredible Years’ parenting programme:
– videotapes shown in group, 3 wks each of • Play
• praise & rewards
• setting limits
• handling misbehaviour
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Antisocial Behaviour Before and after intervention
(percentile level; p<0.0001; Scott et al., 2001)
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Do good parenting programmes in childhood having enduring effects and prevent the emergence of antisocial personality traits?
Long-term follow-up of two controlled trials: The SPACE study
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Antisocial Personality
• APD (Antisocial Personality Disorder) affects 1% of females and 3% of males
• No successful treatment in adulthood• Origins in childhood• Two main components – persistent antisocial
behaviour and callous-unemotional traits – CU traits can be reliably detected by age 7
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Antisocial Personality: Prevention
Evidence from two controlled trials:
a) clinical trial (BMJ) b) community sample (‘SPOKES’)
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Long-term follow up
• Follow up 2005-07 7-10 years later of 94
children now aged 10-17 (mean 13)
• Intention to treat, 74 allocated to IY, 20
controls received treatment as usual
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Parenting effects
• No effect on Alabama qu’re, Parent or Child
• No effect on directly observed parent-youth
interaction (Oregon “hot topics”)
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ODD diagnosis rateat 8 year follow-up (p< 0.007; Scott et al., 2014 )
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Parent SDQ total(p<0.003)
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Youth report home beh(p<0.038)
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Reading score (WORD)
(p< 0.03)
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Youth report school beh(ns)
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Teacher SDQ total(ns)
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Comment• Gratifying to have enduring effects on antisocial
behaviour and antisocial personality traits 7-10 years later
• Surprising to have reading effects – objectively tested
• The lack of effects at school (though a weak measure) and in the community argue for a teacher programme
• Our trial of universal IY in 24 schools, measuring worst 3 kids in class aged 3-6 in Jamaica found effect size of .42 on ODD, .74 on friendship skills (Baker-Henningham, Taylor, Scott & Walker, 2012)
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Factors predicting adolescent aggression Factors predicting adolescent aggression
ANTISOCIAL ‘FRIENDS’
.2
ACADEMIC FAILURE
.2 NEGATIVE PARENTING .3
DEFIANCE, TANTRUMS
.5
3 years
ANTISOCIAL BEHAVIOUR
.6
9 years
AGGRESSIVEDELINQUENCY
15 years
HYPERACTIVITY .2
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Therefore, logical intervention should target more than one risk
factor:
•Improve parenting•Reduce antisocial behaviour•Improve focus and attention•Improve reading attainment•(address delinquent peer group in adolescence)
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the SPOKES Programme in schools
(Scott, Sylva et al 2010, JCPP)
Address a whole population Get them young Engage the most deprived Address child behaviour AND learning Use the most effective interventions Make it normal and fun
PREVENTION AT A PREVENTION AT A POPULATION LEVELPOPULATION LEVEL
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Child Antisocial Child Antisocial Behaviour - Behaviour - PACS Interview scores PACS Interview scores
0.8
0.9
1
1.1
1.2
Pre Post
GroupHelpline
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Child Hyperactivity Child Hyperactivity - PACS Interview Scores - PACS Interview Scores
0.4
0.45
0.5
0.55
0.6
0.65
Pre Post
GroupHelpline
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Child Reading: BAS RA-CA Child Reading: BAS RA-CA
-4
-2
0
2
4
6
8
mo
nth
s d
iffe
ren
ce
Pre Post
GroupHelpline
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HCA Study Questions
Which intervention changes which outcome?
1. Does the IY intervention improve relationships & antisocial behaviour, but not reading?
2. Does the literacy intervention improve child reading but not antisocial behaviour?
3. Does giving both programmes enhance both outcomes?
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Reading Video
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Effect-size of change in antisocial behaviour vs controls (PACS parent interview)all interventions significant at both times
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Effect-size of change in reading vs controls (BAS test)
IY significant at 1 and 2 years, Lit & Combi not
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“An ounce of action is worth a ton of theory”
Friedrich Engels, 1860
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Commissioning Toolkitwww.education.gov.uk/commissioning-toolkit
Over 160 programmes submitted themselves136 met criteria of a parenting programme18 had RCT evidenceWe also evaluated
1 theory & quality of content, 2 Appropriateness for target population 3 quality of training materials & procedures
Correlation between 4 elements 0.7- the notion that there are many excellent unevaluated programmes out there not true
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‘… the habit of self-abuse notably gives rise to a particular and disagreeable form of insanity, characterized by intense self-feeling and conceit, loss of mental energy, hypochondriacal brooding, pitiful vacillation, extreme perversion of feeling, and corresponding derangement of thought, in the earlier stages; and later, by failure of intelligence, nocturnal hallucinations of a painful character, and suicidal or homicidal propensities.’
p. 225
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NAPR/LSE cost-benefit of evidence-based parenting programmes (Bonin et al, 2010)
Worst case
Base case Best case
Savings year 1 per person
-£ 967 - £ 737 £ 196
Total savings (25 years) per person
£ 1,246 £ 4,530 £ 40,284
Years to break even
9 5 1
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TRAINER
PARENTINGPRACTITIONER
PARENT
CHILD
Feedback loops of research contribution
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-0.2
0
0.2
0.4
0.6
0.8
1
1.2
child
agg
ress
ion
impr
ovem
ent
lowest lower third middle third upper third
Skill of professional in delivering programme
Child outcome and professional skill
(5) Develop Quality(Scott, Carby and Rendu 2007)
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Skill in Functional Family Therapy & crime rates
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© Stephen Scott
Proportion & numbers of children in a community of 250,000 people
50% 25,000
5% 2,500
2% 1000
.5%
10% 5,000
10-50% 20,000
multiple complex needs: specialist CAMHS
moderate or severe disorder: CAMHS team
1 or 2 needs: 1º care Parenting advice?
Meets diagnosis: community CAMHS/trained NGO?
behaviour problems at school & home NGO?
No extra needs: Online Parenting Classes?
.5