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Disruptive adolescents in the school system: comparative effectiveness of helping strategies
Journal of Adolescence
Abstract
Large sums of money are often spent on setting up different systems of helping or managing disruptive adolescents in the school system, without reference to objective data on effectiveness. This paper considers 24 alternative systems, scrutinizes the evaluation research on each, and notes that the most expensive systems are not necessarily the most effective. Furthermore, the task of resolving behavioural difficulties may be either under- or over-resourced in individual cases, building in either failure or waste. A guide is given to developing a sequence of intervention strategies of known cost-effectiveness, providing a fail-safe structure for helping disruptive adolescents in educational settings.
The purpose of this article is to show the following: (a) Over a third of incarcerated delinquents are handicapped, needing special education treatment; (b) parallel trends to deinstitutionalize delinquents and to develop alternatives to public school for behaviorally disordered youths are putting some individuals from each category in the same alternative settings; (c) several other stress inducing societal trends are likely to increase the number of these youths; (d) the state of research in the field is poor (particularly lacking in long term evaluations); and (e) the belief that new prosocial behaviors inculcated (especially) by short term treatments will persist without subsequent changed social psychological support for clients is likely to be chimerical.
Investigated, over 1 yr, the use of isolation timeout as a behavioral control intervention in a special educational facility. Ss were 156 students (aged 5 yrs 11 mo to 18 yrs 5 mo) with emotional disturbance. The relationship of timeout to demographic variables was examined for a subsample of 73 students. Results indicate that 12,992 separate timeouts occurred over the academic year. Average time in isolation was 23 hrs per student over the school year. Older students in more restrictive placements were found to spend significantly more time in isolation than were other groups, though much of this difference was due to voluntary timeouts. Alternatives to timeout as a behavior control measure are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Background Bone-saving hip arthroplasty techniques, which facilitate revision, are gaining importance as the number of hip replacements in younger patients increases. Patients and methods 123 CUT femoral neck prostheses (ESKA Implants, Lübeck, Germany) were implanted in 113 patients (average age 53 years) between 1999 and 2002. After a mean follow-up of 5 (3–7) years, we determined the state of 120 prostheses; 3 patients could not be located. 97 patients with 107 prostheses, none of which had been revised, were evaluated clinically and radiographically. Results The median Harris hip score improved from 51 points to 92 points in the unrevised hips. 13 CUT prostheses (11%) had been revised, 7 because of aseptic loosening, 3 because of persisting thigh pain, 1 because of immediate vertical migration, and 2 because of septic loosening. The 5-year survival rate of the CUT prosthesis was 89%. Interpretation The medium-term survival with this type of femoral component is unsatisfactory, with a high rate of aseptic loosening. The surviving prostheses had a good clinical outcome.
To assess the clinical and cost-effectiveness of parent training programmes for the treatment of children with conduct disorder (CD) up to the age of 18 years.
Electronic databases.
For the effectiveness review, relevant studies were identified and evaluated. A quantitative synthesis of behavioural outcomes across trials was also undertaken using two approaches: vote counting and meta-analysis. The economic analysis consisted of reviewing previous economic/cost evaluations of parent training/education programmes and the economic information within sponsor's submissions; carrying out a detailed exploration of costs of parent training/education programmes; and a de novo modelling assessment of the cost-effectiveness of parent training/education programmes. The potential budget impact to the health service of implementing such programmes was also considered.
Many of the 37 randomised controlled trials that met the review inclusion and exclusion criteria were assessed as being of poor methodological quality. Studies were clinically heterogeneous in terms of the population, type of parent training/education programme and content, setting, delivery, length and child behaviour outcomes used. Both vote counting and meta-analysis revealed a consistent trend across all studies towards short-term effectiveness (up to 4 months) of parent training/education programmes (compared with control) as measured by a change in child behaviour. Pooled estimates showed a statistically significant improvement on the Eyberg Child Behaviour Inventory frequency and intensity scales, the Dyadic Parent-Child Interaction Coding System and the Child Behaviour Checklist. No studies reported a statistically significant result favouring control over parent training/education programmes. There were few statistically significant differences between different parent training/education programmes, although there was a trend towards more intensive interventions (e.g. longer contact hours, additional child involvement) being more effective. The cost of treating CD is high, with costs incurred by many agencies. A recent study suggested that by age 28, costs for individuals with CD were around 10 times higher than for those with no problems, with a mean cost of 70,019 pounds sterling. Criminality incurs the greatest cost, followed by educational provision, foster and residential care and state benefits. Only a small proportion of these costs fall on health services. Using a 'bottom-up' costing approach, the costs per family of providing parent training/education programmes range from 629 pounds sterling to 3839 pounds sterling depending on the type and style of delivery. Using the conservative assumption that there are no cost savings from treatment, a total lifetime quality of life gain of 0.1 would give a cost per quality-adjusted life-year of between 38,393 pounds sterling and 6288 pounds sterling depending on the type of programme delivery and setting.
Parent training/education programmes appear to be an effective and potentially cost-effective therapy for children with CD. However, the relative effectiveness and cost-effectiveness of different models (such as therapy intensity and setting) require further investigation. Further research is required on the impact of parent training/education programmes on the quality of life of children with CD and their parents/carers, as well as on longer term child outcomes.
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