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Parenting interventions for the prevention of persistent conduct disorders
Abstract
Background: Conduct disorders are the most common psychiatric disorders in children and may persist into adulthood in about 50% of cases. The costs to society are high and impact many public sector agencies. Parenting programmes have been shown to positively affect child behaviour, but little is known about their potential long-term cost-effectiveness. We therefore estimate the costs of and longer-term savings from evidence-based parenting programmes for the prevention of persistent conduct disorder. Methods: A decision-analytic Markov model compares two scenarios: 1) a 5-year old with clinical conduct disorder receives an evidence-based parenting programme; 2) the same 5-year old does not receive the programme. Cost-savings analysis is performed by comparing the probability that conduct disorder persists over time in each scenario, adopting both a public sector and a societal perspective. If the intervention is successful in reducing persistent conduct disorder, cost savings may arise from reduced use of health services, education support, social care, voluntary agencies and from crimes averted. Results: Results strongly suggest that parenting programmes reduce the chance that conduct disorder persists into adulthood and are cost-saving to the public sector within 5-8 years under base case conditions. Total savings to society over 25 years are estimated at £16,435 per family, which compares with an intervention cost in the range of £952-£2,078 (2008/09 prices).
... Controlled trials have shown short-term improvements in children's behaviour following parenting programmes in reducing harsh parenting practices and children's behaviour problems in the short term [13,14]. However, the most hard-to-help families are missing from research examining effectiveness of interventions and little is known about what aspects of support might be most likely to improve outcomes [15,16]. ...
Background:
Many childhood risk factors are known to be associated with children's future antisocial and criminal behaviour, including children's conduct disorders and family difficulties such as parental substance abuse. Some families are involved with many different services but little is known about what middle childhood factors moderate the risk of poor outcomes. This paper reports the quantitative component of a mixed methods study investigating what factors can be addressed to help families improve children's outcomes in the longer term. The paper examines six hypotheses, which emerged from a qualitative longitudinal study of the service experiences of eleven vulnerable families followed over five years. The hypotheses concern factors which could be targeted by interventions, services and policy to help reduce children's behaviour problems in the longer term.
Methods:
The hypotheses are investigated using a sample of over one thousand children from the Avon Longitudinal Study of Parents and Children (ALSPAC). Multiple logistic regression examines associations between potentially-moderating factors (at ages 5-10) and antisocial and criminal behaviour (at ages 16-21) for children with behaviour problems at baseline.
Results:
ALSPAC analyses support several hypotheses, suggesting that the likelihood of future antisocial and criminal behaviour is reduced in the presence of the following factors: reduction in maternal hostility towards the child (between ages 4 and 8), reduction in maternal depression (between the postnatal period and when children are age 10), mothers' positive view of their neighbourhood (age 5) and lack of difficulty paying the rent (age 7). The evidence was less clear regarding the role of social support (age 6) and mothers' employment choices (age 7).
Conclusion:
The findings suggest, in conjunction with findings from the separate qualitative analysis, that improved environments around the child and family during middle childhood could have long-term benefits in reducing antisocial and criminal behaviour.
... 4. Bonin et al. (2011a;see also 2011b): this is an economic modelling study undertaken for the Department of Health as a part of a wider project on the economic case for mental health promotion and mental illness prevention. ...
... Recent modelling work has been done in an English context to assess the costs and benefits of parenting programmes to prevent conduct disorders 33 . Over a ten year period it reported a return on investment of nearly €8 for every €1 spent on parenting programmes. ...
Poor mental health has a significant economic impact on the health system and the wider economy
in Europe, with implications for the potential achievement of the Europe 2020 strategy on economic
growth. This brief primer considers what is known about the potential short, mid and longer term
economic benefits of actions across the life course focused on mental health promotion, mental
disorder prevention and early intervention. Actions that can be undertaken both within and external
to the mental health system are highlighted, drawing on recent economic analyses prepared in a UK
context, supplemented by data from other parts of Europe and elsewhere.
There is considerable variation in the strength of the evidence base and in the time period required
to achieve a return on investment. The most attractive actions include early actions in childhood
which can have substantial benefits that last well into adulthood, as well as interventions to promote
health in workplaces. Improved job retention rates reduce the need to pay social welfare payments
related to employment and disability. Workplace health promotion activities might also reduce the
risk of early retirement due to poor mental health.
Economic restructuring is not just associated with the current economic climate it is a constant
activity; there may also be interest in interventions to strengthen the mental health and resilience of
those who have been made unemployed or are at risk of unemployment or enforced change of role
at work. Loss of job, or downsizing of role have been associated with a reduction in mental health;
again early actions can reduce the risks of these events and their resource consequences for health
care systems.
Other activities examined here include tackling post natal depression, reducing the risk of suicide,
early identification of psychosis, promoting the mental health of older people, the use of debt and
financial advice services, tackling chronic co-morbid physical and mental health problems, and
addressing the issue of medically unexplained systems.
In this paper we explain some of the difficulties of providing forecasts of the financial benefits of early intervention programmes, focussing on those delivered during the early childhood period. We highlight the diversity of early intervention, and the complexity and multiplicity of outcomes. We summarise recent work at the Early Intervention Foundation to assess the evidence on the impacts of early intervention, recognising the diversity of approaches to delivery and the importance of innovation and local practice as well as of rigorous approaches to evaluating causal effects. We also describe new ways of assessing accurately the local fiscal costs of late intervention and consider the implications of this for addressing the well-established barriers to investment in prevention. Our analysis brings to the fore gaps in the evidence from which even the most rigorous ‘gold-standard’ research is not immune. These limitations prevent the production of an accurate and realistic cost-benefit ratio or net present value for the majority of programmes as delivered in practice. We suggest some paths towards a firmer foundation of evidence and a better alignment of evidence and policy.
Background: Conduct disorders are the most common psychiatric disorders in children and may persist into adulthood in about 50% of cases. The costs to society are high and impact many public sector agencies. Parenting programmes have been shown to positively affect child behaviour, but little is known about their potential long-term cost-effectiveness. We therefore estimate the costs of and longer-term savings from evidence-based parenting programmes for the prevention of persistent conduct disorder. Methods: A decision-analytic Markov model compares two scenarios: 1) a 5-year old with clinical conduct disorder receives an evidence-based parenting programme; 2) the same 5-year old does not receive the programme. Cost-savings analysis is performed by comparing the probability that conduct disorder persists over time in each scenario, adopting both a public sector and a societal perspective. If the intervention is successful in reducing persistent conduct disorder, cost savings may arise from reduced use of health services, education support, social care, voluntary agencies and from crimes averted. Results: Results strongly suggest that parenting programmes reduce the chance that conduct disorder persists into adulthood and are cost-saving to the public sector within 5-8 years under base case conditions. Total savings to society over 25 years are estimated at £16,435 per family, which compares with an intervention cost in the range of £952-£2,078 (2008/09 prices).
Conduct disorders are the most common psychiatric disorders in children and may persist into adulthood in about 50% of cases. The costs to society are high and impact many public sector agencies. Parenting programmes have been shown to positively affect child behaviour, but little is known about their potential long-term cost-effectiveness. We therefore estimate the costs of and longer-term savings from evidence-based parenting programmes for the prevention of persistent conduct disorder.
A decision-analytic Markov model compares two scenarios: 1) a 5-year old with clinical conduct disorder receives an evidence-based parenting programme; 2) the same 5-year old does not receive the programme. Cost-savings analysis is performed by comparing the probability that conduct disorder persists over time in each scenario, adopting both a public sector and a societal perspective. If the intervention is successful in reducing persistent conduct disorder, cost savings may arise from reduced use of health services, education support, social care, voluntary agencies and from crimes averted.
Results strongly suggest that parenting programmes reduce the chance that conduct disorder persists into adulthood and are cost-saving to the public sector within 5-8 years under base case conditions. Total savings to society over 25 years are estimated at £16,435 per family, which compares with an intervention cost in the range of £952-£2,078 (2008/09 prices).
Effective implementation of evidence-based parenting programmes is likely to yield cost savings to the public sector and society. More research is needed to address evidence gaps regarding the current level of provision, longer-term effectiveness and questions of implementation, engagement and equity.
This work established for the first time estimates for the full impact of crime on society, setting out methodology for valuing each of the main categories of crime. It has become a standard text for researchers and criminal justice agencies around the world.
It estimated that in 1999-2000 the cost of all crime in England and Wales was around £60bn. On average, a serious violent crime is estimated to cost society £19,000, compared to £4,800 for a vehicle theft or a robbery, and £510 for criminal damage. The average impact of a homicide is estimated at £1.1 million. Violent crimes represent around 40% of the overall cost of crime, compared with only 3% of the number of crimes.
The estimates were prepared to provide an indicator to show how well the criminal justice system is performing in tackling the wider impacts of crime on society - such as victim trauma, damage to and loss of property, and time spent responding to crime and dealing with its consequences. They can help us prioritise, focusing resources on policies that have the biggest impact on the harm and victim trauma caused by crime, rather than simply the number of crimes.
This paper presents initial validation data for a behavioral inventory of child conduct problems. The 36‐item Eyberg Child Behavior Inventory (ECBI) was completed by mothers of two‐ to seven‐year‐old children from several samples of problem and non‐problem behavior children. Results from this study indicated the usefulness of the ECBI in discriminating between problem and non‐problem children, for purposes of evaluation; provided data on the non‐problem child as a guideline in defining reasonable therapeutic goals; and demonstrated the ability of the ECBI to reflect the change following treatment intervention.
A number of researchers and policy makers have recently argued that the most effective way of dealing with long-run disadvantage and the intergenerational transmission of poverty is through early childhood intervention and in particular policies aimed at supporting the family. This study was part of a randomised evaluation of the Incredible Years Program, which is aimed at improving the skills and parenting strategies of parents who have children with conduct problems. The results show that the treatment significantly reduced behavioural problems in young children. Furthermore our detailed cost analysis, when combined with a consideration of the potential long-run benefits associated with the programme, suggest that the long-run rate of return to society from this program is likely to be relatively high.
An antisocial lifestyle is associated with injury but also with less organic illness up to the age of 32. It is not known if these associations persist into the fifth decade.
Injury and illness data were collected prospectively in the longitudinal Cambridge study in delinquent development at age 43-48. Hypotheses were that childhood predictors of antisocial behaviour and offending and antisocial behaviour at ages up to 32 would be associated with poorer health at age 48.
Childhood and parental predictors of offending, self-reported delinquency at age 32 and convictions were significantly associated with death and disability by age 48. A model comprising three factors: any antisocial behaviour and any parental risk factor at age 8-10 and any antisocial behaviour at age 27-32 best discriminated death or disability. Two factors: conviction between ages 10-18 and any antisocial behaviour at age 8-10 discriminated almost as well.
Death and disability by age 48 were strongly associated with antisocial behaviour at ages 8-10 and 27-32, convictions and impulsivity during adolescence and parental predictors of offending at age 8-10. Preventing childhood and adolescent antisocial behaviour and offending may also prolong life and prevent disability among those who would otherwise offend.
Conduct problems are common, disabling and costly. The prognosis for children with conduct problems is poor, with outcomes in adulthood including criminal behaviour, alcoholism, drug abuse, domestic violence, child abuse and a range of psychiatric disorders. There has been a rapid expansion of group based parent-training programmes for the treatment of children with conduct problems in a number of countries over the past 10 years. Existing reviews of parent training have methodological limitations such as inclusion of non-randomised studies, the absence of investigation for heterogeneity prior to meta-analysis or failure to report confidence intervals. The objective of the current study was to systematically review randomised controlled trials of parenting programmes for the treatment of children with conduct problems.
Standard systematic review methods were followed including duplicate inclusion decisions, data extraction and quality assessment. Twenty electronic databases from the fields of medicine, psychology, social science and education were comprehensively searched for RCTs and systematic reviews to February 2006. Inclusion criteria were: randomised controlled trial; of structured, repeatable parenting programmes; for parents/carers of children up to the age of 18 with a conduct problem; and at least one measure of child behaviour. Meta-analysis and qualitative synthesis were used to summarise included studies.
57 RCTs were included. Studies were small with an average group size of 21. Meta-analyses using both parent (SMD -0.67; 95% CI: -0.91, -0.42) and independent (SMD -0.44; 95% CI: -0.66, -0.23) reports of outcome showed significant differences favouring the intervention group. There was insufficient evidence to determine the relative effectiveness of different approaches to delivering parenting programmes.
Parenting programmes are an effective treatment for children with conduct problems. The relative effectiveness of different parenting programmes requires further research.
To describe long term outcomes associated with externalising behaviour in adolescence, defined in this study as conduct problems reported by a teacher, in a population based sample.
Longitudinal study from age 13-53.
The Medical Research Council National Survey of Health and Development (the British 1946 birth cohort).
3652 survey members assessed by their teachers for symptoms of externalising behaviour at age 13 and 15.
Mental disorder, alcohol abuse, relationship difficulties, highest level of education, social class, unemployment, and financial difficulties at ages 36-53.
348 adolescents were identified with severe externalising behaviour, 1051 with mild externalising behaviour, and 2253 with no externalising behaviour. All negative outcomes measured in adulthood were more common in those with severe or mild externalising behaviour in adolescence, as rated by teachers, compared with those with no externalising behaviour. Adolescents with severe externalising behaviour were more likely to leave school without any qualifications (65.2%; adjusted odds ratio 4.0, 95% confidence interval 2.9 to 5.5), as were those with mild externalising behaviour (52.2%; 2.3, 1.9 to 2.8), compared with those with no externalising behaviour (30.8%). On a composite measure of global adversity throughout adulthood that included mental health, family life and relationships, and educational and economic problems, those with severe externalising behaviour scored significantly higher (40.1% in top quarter), as did those with mild externalising behaviour (28.3%), compared with those with no externalising behaviour (17.0%).
Adolescents who exhibit externalising behaviour experience multiple social and health impairments that adversely affect them, their families, and society throughout adult life.
To compare the cumulative costs of public services used through to adulthood by individuals with three levels of antisocial behaviour in childhood. Design: Costs applied to data of 10 year old children from the inner London longitudinal study selectively followed up to adulthood.
Inner London borough.
142 individuals divided into three groups in childhood: no problems, conduct problems, and conduct disorder.
Costs in 1998 prices for public services (excluding private, voluntary agency, indirect, and personal costs) used over and above basic universal provision.
By age 28, costs for individuals with conduct disorder were 10.0 times higher than for those with no problems (95% confidence interval of bootstrap ratio 3.6 to 20.9) and 3.5 times higher than for those with conduct problems (1.7 to 6.2). Mean individual total costs were 70 019 pounds sterling for the conduct disorder group (bootstrap mean difference from no problem group 62 pound sterling; 898 pound sterling 22 692 pound sterling to 117 pound sterling) and 24 324 pound sterling (16 707 pound sterling; 6594 pound sterling to 28 149 pound sterling) for the conduct problem group, compared with 7423 pound sterling for the no problem group. In all groups crime incurred the greatest cost, followed by extra educational provision, foster and residential care, and state benefits; health costs were smaller. Parental social class had a relatively small effect on antisocial behaviour, and although substantial independent contributions came from being male, having a low reading age, and attending more than two primary schools, conduct disorder still predicted the greatest cost.
Antisocial behaviour in childhood is a major predictor of how much an individual will cost society. The cost is large and falls on many agencies, yet few agencies contribute to prevention, which could be cost effective.
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.
Persistent antisocial behaviour is the most common mental health problem in childhood and has widespread effects, yet little is known about what it costs.
To identify the costs incurred by children with antisocial behaviour in the UK, and who pays these costs.
Eighty children aged 3-8 years referred to mental health services were studied using the Client Service Receipt Inventory for Childhood.
The mean annual total cost was pound 5960 (median 4597, range 48-19 940). The services used were mainly the National Health Service, education and voluntary agencies, but the greatest cost burden, pound 4637, was borne by the family. Higher cost was predicted by more severe behaviour and being male.
The annual cost of severe antisocial behaviour in childhood in the UK is substantial and widespread, involving several agencies, but the burden falls most heavily on the family. Wider uptake of evidence-based interventions is likely to lead to considerable economic benefits in the short term, and probably even more in the long term.
To investigate the cost effectiveness of a parenting programme.
An incremental cost effectiveness analysis alongside a pragmatic randomised controlled trial of the effectiveness of a group parenting programme delivered through Sure Start in the community.
Sure Start areas in north and mid Wales.
Parents of 116 children aged 36-59 months (87% of the clinical sample) at risk of developing conduct disorders defined by scoring over the clinical cut off on the Eyberg child behaviour inventory). Children were identified by health visitors and recruited by the research team.
The Webster-Stratton Incredible Years basic parenting programme or a six month waiting list control.
Incremental cost per unit of improvement on the intensity score of the Eyberg child behaviour inventory.
The bootstrapped incremental cost effectiveness ratio point estimate was 73 pounds sterling (109 euros, 10,666) to bring the child with the highest intensity score to below the clinical cut-off point and 1344 (2006 euros, 194) per point increase in intensity score, there is an 83.9% chance of the intervention being cost effective. The mean cost per child attending the parenting group was 1934 pounds sterling (2887 euros, 2506) for 12 children, including initial costs and materials for training group leaders. When we categorised the sample into relatively mild, moderate, and severe behaviour groups based on intensity scores at baseline the intervention seemed more cost effective in those with the highest risk of developing conduct disorder.
This parenting programme improves child behaviour as measured by the intensity score of the Eyberg child behaviour inventory at a relatively low cost and was cost effective compared with the waiting list control. This parenting programme involves modest costs and demonstrates strong clinical effect, suggesting it would represent good value for money for public spending.
The Triple P Positive Parenting Program is a multilevel parenting program to prevent and offer treatment for severe behavioral, emotional, and developmental problems in children. The aim of this meta-analysis is to assess the effectiveness of Triple P Level 4 interventions in the management of behavioral problems in children by pooling the evidence from relevant literature that included Level 4 Triple P interventions. Level 4 intervention is indicated if the child has multiple behavior problems in a variety of settings and there are clear deficits in parenting skills. Results indicate that Level 4 of Triple P interventions reduced disruptive behaviors in children. These improvements were maintained well over time, with further improvements in long-term follow-up. These effects support the widespread adoption and implementation of Triple P that is taking place in an increasing number of countries in quite diverse cultural contexts around the world.
Background:
Mental health problems are common, and there is evidence from a range of studies to suggest that a number of factors relating to maternal psychosocial health can have a significant effect on the mother-infant relationship, and that this can have consequences for both the short and long-term psychological health of the child. The use of parenting programmes is increasing in the UK and evidence of their effectiveness in improving outcomes for mothers is now required.
Objectives:
The objective of this review is to address whether group-based parenting programmes are effective in improving maternal psychosocial health including anxiety, depression, and self-esteem.
Search strategy:
A range of biomedical, social science, educational and general reference electronic databases were searched including MEDLINE, EMBASE CINAHL, PsychLIT, ERIC, ASSIA, Sociofile and the Social Science Citation Index. Other sources of information included the Cochrane Library (SPECTR, CENTRAL), and the National Research Register (NRR).
Selection criteria:
Only randomised controlled trials were included in which participants had been randomly allocated to an experimental and a control group, the latter being either a waiting-list, no-treatment or a placebo control group. Studies had to include at least one group-based parenting programme, and one standardised instrument measuring maternal psychosocial health.
Data collection and analysis:
A systematic critical appraisal of all included studies was undertaken using a modified version of the Journal of the American Medical Association (JAMA) published criteria. The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group, by the pooled standard deviation, to produce an effect size. Where appropriate the results were then combined in a meta-analysis using a fixed-effect model, and 95% confidence intervals were used to assess the significance of the findings.
Main results:
A total of 23 studies were included in the review but only 17 provided sufficient data to calculate effect sizes. The 17 studies provided a total of 59 assessments of outcome on a range of aspects of psychosocial functioning including depression, anxiety, stress, self-esteem, social competence, social support, guilt, mood, automatic thoughts, dyadic adjustment, psychiatric morbidity, irrationality, anger and aggression, mood, attitude, personality, and beliefs. There was only sufficient data, however, on five outcomes (depression; anxiety/stress; self-esteem; social support; and relationship with spouse/marital adjustment) to combine the results in a meta-analysis. The meta-analyses show statistically significant results favouring the intervention group as regards depression; anxiety/stress; self-esteem; and relationship with spouse/marital adjustment. The meta-analysis of the social support data, however, showed no evidence of effectiveness. These results suggest that parenting programmes, irrespective of the type (or content) of programme, can be effective in improving important aspects of maternal psycho-social functioning. Of the data summarising the effectiveness of the different types of parenting programmes, which it was not possible to combine in a meta-analysis, approximately 22% of the outcomes measured, showed significant differences between the intervention group and the control group. A further 40% showed medium to large non-significant differences favouring the intervention group. Approximately one-third of outcomes showed small non-significant differences or no evidence of effectiveness. A meta-analysis of the follow-up data on three outcomes was also conducted - depression, self-esteem and relationship with spouse/marital adjustment. The results show that there was a continued improvement in self-esteem, depression and marital adjustment at follow-up, although the latter two findings were not statistically significant.
Reviewer's conclusions:
It is suggested that parenting programmes can make a significant contribution to short-term psychosocial health in mothers, and that the limited follow-up data available suggest that these are maintained over time. However, the overall paucity of long-term follow-up data points to the need for further evidence concerning the long-term effectiveness of parenting programmes on maternal mental health. Furthermore, it is suggested that some caution should be exercised before the results are generalised to parents irrespective of the level of pathology present, and that further research is still required.
Objective: To test the hypothesis that a community based intervention by secondary child and adolescent mental health services would be significantly more effective and less costly than a hospital based intervention. Design: Open study with two randomised parallel groups. Setting: Two health districts in the north of England. Participants: Parents of 3 to 10 year old children with behavioural disorder who had been referred to child and adolescent mental health services. Intervention: Parental education groups. Main outcome measures: Parents' and teachers' reports of the child's behaviour, parental depression, parental criticism of the child, impact of the child's behaviour on the family. Results: 141 subjects were randomised to community (n=72) or hospital (n=69) treatment. Primary outcome data were obtained on 115 (82%) cases a year later. Intention to treat analyses showed no significant differences between the community and hospital based groups on any of the outcome measures, or on costs. Parental depression was common and predicted the child's outcome. Conclusions: Location of child mental health services may be less important than the range of services that they provide, which should include effective treatment for parents' mental health problems.
Examines attrition in the treatment of children and reviews current investigations regarding attrition, the status of the literature, issues that guide research, and other factors that may influence substantive findings. Attrition or loss of cases over the course of therapy is seen as an issue that raises broad concerns in research and clinical practice. The need for sharper conceptualization of attrition and the factors that contribute to its many manifestations are emphasized. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This paper estimates the rate of return to the HighScope Perry Preschool Program, an early intervention program targeted toward disadvantaged African-American youth. Estimates of the rate of return to the Perry program are widely cited to support the claim of substantial economic benefits from preschool education programs. Previous studies of the rate of return to this program ignore the compromises that occurred in the randomization protocol. They do not report standard errors. The rates of return estimated in this paper account for these factors. We conduct an extensive analysis of sensitivity to alternative plausible assumptions. Estimated annual social rates of return generally fall between 7 and 10%, with most estimates substantially lower than those previously reported in the literature. However, returns are generally statistically significantly different from zero for both males and females and are above the historical return on equity. Estimated benefit-to-cost ratios support this conclusion.
Background:
Conduct disorder (antisocial conduct), attention deficit problems and anxiety in childhood have negative effects on individuals during their childhood, on their families, and often into adulthood.
Aims of the study:
To quantify the connections between childhood antisocial conduct, attention deficit and anxiety, and some adulthood economic consequences.
Methods:
Data from a British birth cohort study were examined for links between behavioural and emotional problems in childhood, and occupational status and earnings in adulthood, after adjusting for individual and family covariates.
Results:
The effects of antisocial conduct on adult labour market outcomes were complex. Results for males with antisocial conduct at age 10 showed a higher probability of being unemployed at age 30 (after adjustment for other factors). However, males with antisocial conduct at age 10 had higher earnings than those without such behaviour, again after adjusting for other factors. There were no such differences for females with antisocial conduct. Attention deficit problems at age 10 were associated with lower employment rates, worse jobs, lower earnings if employed, and lower expected earnings overall - for both males and females. Anxiety problems were associated with lower earnings. Other childhood factors associated with worse adulthood economic outcomes included cognitive attainment, living in a disadvantaged neighbourhood, mother's educational qualifications, family income and being looked after by a local authority.
Discussion:
Links between antisocial conduct and attention deficit in childhood and high adulthood personal and societal costs support arguments for effective interventions to prevent and treat behavioural problems in childhood. However, the cost-effectiveness of such interventions still needs to be considered carefully.
Implications for policy:
Childhood mental health problems are strongly linked to adverse adulthood experiences across a number of domains. Early detection and intervention might head off many of these negative outcomes for children, their families and wider society. The positive impact of antisocial conduct on earnings needs further examination: it is not necessarily counter-intuitive, but it raises interesting policy questions.
Implications for further research:
The long-term outcomes of childhood problems and interventions need further study, as do the pathways connecting childhood morbidity, adulthood outcomes and other potential intervening factors.
Evidence about the cost-effectiveness of interventions in children's services can help decision-makers make more efficient use of scarce resources. We returned to six somewhat disparate interventions on which we had collated research evidence identified by service planners and practitioners as relevant to the well-being of children in the course of the Economic and Social Research Council-funded What Works for Children project. These are home visiting, parenting, cognitive–bahavioural therapy, mentoring, traffic calming and breakfast club interventions. We aimed to explore the nature and extent of evidence on cost-benefit and cost effectiveness for these measures. We conducted searches for studies that looked at the costs as well as the effectiveness of the six interventions and found 24 studies matching our inclusion criteria. The studies were diverse in terms of study design and economic methods (including economic modelling and willingness to pay). Studies relating to parenting programmes and traffic calming gave the most positive indication that the interventions may be cost-effective for the outcomes in question. The remainder of the studies did not give a clear picture, in large part because of a lack of demonstration that the intervention was effective.
The typical pattern for intervention outcome studies for conduct problems has been for effect sizes to dissipate over time with decreasing effects across subsequent follow-ups.
To establish whether the short-term positive effects of a parenting programme are sustained longer term. To observe trends, and costs, in health and social service use after intervention.
Parents with children aged 36-59 months at risk of developing conduct disorder (n = 104) received intervention between baseline and first follow-up (6 months after baseline n = 86) in 11 Sure Start areas in North Wales. Follow-ups two (n = 82) and three (n = 79) occurred 12 and 18 months after baseline. Child problem behaviour and parenting skills were assessed via parent self-report and direct observation in the home.
The significant parent-reported improvements in primary measures of child behaviour, parent behaviour, parental stress and depression gained at follow-up one were maintained to follow-up three, as were improved observed child and parent behaviours. Overall, 63% of children made a minimum significant change (0.3 standard deviations) on the Eyberg Child Behavior Inventory problem scale between baseline and follow-up (using intention-to-treat data), 54% made a large change (0.8 standard deviations) and 39% made a very large change (1.5 standard deviations). Child contact with health and social services had reduced at follow-up three.
Early parent-based intervention reduced child antisocial behaviour and benefits were maintained, with reduced reliance on health and social service provision, over time.
The Cambridge Study in Delinquent Development is a prospective longitudinal survey of 411 London males from ages 8 years old to 32 years old. This article investigates the prediction of adolescent aggression (ages 12-14 years old), teenage violence (ages 16-18 years old), adult violence (age 32 years old), and convictions for violence. Generally, the best predictors were measures of economic deprivation, family criminality, poor child-rearing, school failure, hyperactivity-impulsivity-attention deficit, and antisocial child behavior. Similar predictors applied to all four measures of aggression and violence. It is concluded that aggression and violence are elements of a more general antisocial tendency, and that the predictors of aggression and violence are similar to the predictors of antisocial and criminal behavior in general.
To test the hypothesis that a community based intervention by secondary child and adolescent mental health services would be significantly more effective and less costly than a hospital based intervention.
Open study with two randomised parallel groups.
Two health districts in the north of England.
Parents of 3 to 10 year old children with behavioural disorder who had been referred to child and adolescent mental health services. Intervention: Parental education groups.
Parents' and teachers' reports of the child's behaviour, parental depression, parental criticism of the child, impact of the child's behaviour on the family.
141 subjects were randomised to community (n=72) or hospital (n=69) treatment. Primary outcome data were obtained on 115 (82%) cases a year later. Intention to treat analyses showed no significant differences between the community and hospital based groups on any of the outcome measures, or on costs. Parental depression was common and predicted the child's outcome.
Location of child mental health services may be less important than the range of services that they provide, which should include effective treatment for parents' mental health problems.
Disruptive behaviour disorders, including conduct disorder, affect at least 10% of children and are the most common reasons for referral to children's mental health services. The long-term economic impact on society of unresolved conduct disorder can exceed pound sterling 1 million for one individual over their lifetime.
The aim of this study was to estimate, from a multi-sectoral service perspective, the longer term cost-effectiveness of an intensive practice based parenting programme for children with severe behavioural problems as compared to a standard treatment, on a pilot basis.
A six-month pragmatic controlled trial was conducted involving forty-two families who had been referred to a Child and Adolescent Mental Health Service (CAMHS) because of severe child behavioural problems. The families were randomly allocated into either the standard or intensive, practice-based treatment arms of the trial. At baseline, children were aged 2 to 10 years. The externalising T-scale of the Child Behaviour Check List (CBCL) was used as the primary outcome measure. Follow-up studies were conducted at 6 months and four years post-intervention. At the four-year follow up point the two treatments were subjected to an incremental cost-effectiveness analysis. This analysis was enabled by the collection of cost data with respect to the provision of the intensive and standard treatments in terms of therapeutic contact time and also participants' use of health, special educational and social services usage by means of a Client Service Receipt Inventory.
Both groups exhibited improved behaviour at six month follow-up, but only the practice based treatment group showed sustained improvement at the four-year follow-up. An independent t-test revealed a significant difference between group mean scores at four-year follow-up (p = 0.027). The research found a median bootstrap ICER estimate of pound sterling 224 From the cost-effectiveness acceptability curve (CEAC) it was found that 89.6% of the cost-effectiveness plane represented a cost saving over the control intervention while 99.9% represented an improvement in effect. Therefore the intensive intervention could not be said to differ significantly from the control intervention on the basis of costs or effects. However under certain circumstances requiring judgement the intensive intervention could be cost-effective.
Training interventions for the parents of children with severe conduct disorders currently take the form of a number of behavioural strategies provided by a CAMHS team including the reinforcement of appropriate behaviours and parent record-keeping. An alternative treatment was then considered that included all the aspects provided by the standard treatment (with the exception of agreeing written goals) and also added five-hour sessions of unit-based treatment during which videotaped recording of parent-child interactions were used to give feedback to parents and to provide the opportunity for behavioural rehearsal. The findings of the current research indicate that this alternative treatment may be more cost-effective than the standard intervention under certain circumstances.
It can be concluded on a pilot basis that while the CEAC failed to show a significant difference between costs and effects for the intensive treatment, under circumstances of resource/effect trade offs the treatment could be said to be cost-effective. IMPLICATIONS FOR HEALTH CARE PROVISION, USE AND POLICIES: Health and social care policy and commissioning must be evidence based. Although the analysis in this paper should be considered a pilot due to the small sample size our results suggest that investment by health services and social services in practice-based parenting interventions may well be less costly and more effective in the longer-run than the standard practice involving giving management advice to parents.
It would be of interest for further research to continue to follow up the work done in this study with a larger cohort of subjects to further establish the effective components of parenting programmes and their relative costs and benefits both at intervention and over time.
There is evidence from a range of studies to suggest that adverse maternal psychosocial health can have an impact on the parent-infant relationship and potentially lead to adverse child outcomes in the longer term. Parenting programmes are increasingly being used to promote the well-being of parents and children, and this review aims to establish whether they can improve maternal psycho-social health in particular. The findings of the review are based on a total of 23 studies and these have been classified into five groups according to the theoretical approach underpinning the programme - behavioural, cognitive-behavioural, multi-modal, behavioural-humanistic and rational-emotive therapy. The 23 studies produced a total of 59 assessments of maternal health, including measures of maternal depression, anxiety, and self-esteem. The combined data show that parenting programmes can be effective in improving a range of aspects of maternal psychosocial functioning. While it was not possible to compare the effectiveness of the programmes in the five different categories, all of the programmes reviewed were successful in producing positive change in maternal psychosocial health. Further research is needed to clarify some of the questions arising from this review.
A meta-analysis of 63 peer-reviewed studies evaluated the ability of parent training programs to modify disruptive child behaviors and parental behavior and perceptions. This analysis extends previous work by directly comparing behavioral and nonbehavioral programs, evaluating follow-up effects, isolating dependent variables expressly targeted by parent training, and examining moderators. Effects immediately following treatment for behavioral and nonbehavioral programs were small to moderate. For nonbehavioral programs, insufficient studies precluded examining follow-up effects. For behavioral programs, follow-up effects were small in magnitude. Parent training was least effective for economically disadvantaged families; importantly, such families benefited significantly more from individually delivered parent training compared to group delivery. Including children in their own therapy, separate from parent training, did not enhance outcomes.
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