IN REVIEW
Addressing disruptive behaviours
Also in this issue
- IN COMMENTARY
Disruptive behaviours: The numbers, the causes and the costs of not intervening - IN REVIEW
Addressing disruptive behaviours - IN FOCUS
The latest evidence on Multi-Systemic Therapy (MST) - IN PRACTICE
Applying the research evidence
Given the high costs associated with severe disruptive behaviours, addressing these concerns needs to be a priority. In our 2004 report, Preventing and Treating Conduct Disorder in Children and Youth1, we identified 19 prevention programs demonstrating significant reductions in disruptive behaviours. The most effective programs were Fast Track, Perry Preschool, John Hopkins and Nurse Home Visitation. (Original articles for interventions described in the Quarterly may be obtained from the Health and Human Services Library.
These successful programs all focused on either parent training or child
skills training involving communication, problem solving, impulse control
and behaviour management. All programs targeted high-risk children and
families. In addition to being effective, the Perry Preschool and Nurse
Home Visitation programs produced net cost-savings.
In the same report, we reviewed seven articles on five psychosocial treatments
including family- and community-based programs. All programs, including
The Incredible Years (Videotape modelling), Behavioural Parent Training,
Parent Training, Multidimensional Treatment Foster Care and Multi-Systemic
Therapy (MST), demonstrated significant reductions in symptoms of CD. (Updates
from a recently published review of MST are highlighted in the next article
of this issue.)
Overall, the research evidence was clear that most children with CD can be helped by early interventions to aid at-risk families. Given the growing body of research on CD, here we update our previous report by examining newly-published high-quality evidence on preventing and treating CD.
Many of the known causes of children’s behaviour problems, such as parenting difficulties, can be addressed through prevention programs
How we reviewed the research
Our research team conducted a systematic review of the recent research on effective prevention and treatment programs for serious disruptive behaviours. We searched for randomized-controlled trials (RCTs) published since our previous report on interventions for preventing and treating CD in children aged 0 to 18 years. To be considered effective, interventions had to show significant reductions in at least one diagnostic measure or two symptom measures at follow-up. (See our first issue of the Quarterly for a complete description of our standard methodology.) We searched the databases Medline, PsycINFO, CINAHL and CENTRAL.
What we learned
Of the 80 articles initially identified and assessed, four articles describing three RCTs met our inclusion criteria. All were on prevention. No RCTs addressing treatment met criteria. The accepted RCTs investigated three prevention programs: Early Impact (EI)2; SAFEChildren3; and Early Risers Skills for Success.4,5 The table below details intervention and participant characteristics along with outcomes for these programs.
Newly Evaluated Conduct Disorder Prevention Programs
| Program (Country) |
Child Ages (yrs) |
Intervention Content, Provider & Location | Type & Duration | Findings for Conduct Symptoms |
Early Impact
Program2 |
4-5 |
Child SST delivered by teachers & behavioral consultants in schools & group PT delivered by clinicians in school & homes |
Universal PT: 3 2-hr sessions |
No significant symptom or diagnostic reductions at 6-mo follow-up |
SAFEChildren3 |
6 |
Child academic tutoring & group PT delivered by unspecified individuals in schools |
Targeted: inner-city children Tutoring: 2 30-min sessions over 22 wks PT: 22 wks |
No significant symptom reductions at 6-mo follow-up for total targeted sample Significant symptom reductions at 6-mo follow-up for subsample of highest risk children |
Early Risers “Skills
for Success” Program4, 5 |
5-6 |
Group child SST, homework assistance, in-school mentoring, creative arts & recreational programming delivered by family advocates & school staff in neighborhood centres & schools (Core)* Family-focused support including brief health & human services interventions delivered by family advocates in homes (Flex) |
Targeted: inner-city, aggressive children Core: 86 hrs (average; with 236 hrs max.) over 24 mos Flex: 9.6 hrs (average) over 18 mos |
No significant symptom reductions at 12-mo follow-up for total targeted sample Significant symptom reductions at 12-mo follow-up for subsample of highest risk children |
SST = Social skills training PT = Parenting training CD = Conduct disorder
*4 groups: ¼ received core; ¼ received core + flex; ¼ no
intervention control; ¼ normative sample control
All the programs had a child-focused component. Early Impact and Early Risers both included social skills training which focused on teaching children about positive interactions including communication, friendship formation, social problem-solving and self-control. Early Impact also included creative arts and recreation programming with a highly structured behaviour-modification program implemented across all program activities. In contrast, the child intervention component of SAFEChildren involved academic tutoring focused on phonic-based reading.
Highlight
The Incredible Years: Helping parents create healthy environments for children
Webster-Stratton’s Incredible Years is a well-evaluated parenting program designed to prevent and treat conduct disorder in children. It promotes positive parenting by teaching parents: to provide praise and incentives; to build healthy parent-child relationships; and to apply appropriate behaviour management strategies including limit setting and non-aversive consequences. For the first time, an evaluation of the The Incredible Years prevention program was conducted in a community (“real world”) setting.
In their just-published article*, Hutchings and colleagues reported on an RCT of this program used with 153 parents of three and four year old children, 60% of who were boys.1 The families were from socially disadvantaged communities in Wales, with children identifyed as being at risk for developing conduct disorder. Parents participated in 12 weekly sessions led by two practitioners using collaborative teaching approaches including: role play; modeling; discussion; skills practice; and analyses of taped family interactions.
To encourage attendance, parents were provided with transportation and meals. All children of participating parents showed significantly reduced antisocial and hyperactive behaviours as well as increased self-control compared to the control group. As well, parents who participated in the program showed more positive parenting behaviours than those in the control group.
The authors concluded that the Incredible Years basic parenting program used in a “real world setting” reduced key risk factors for developing conduct disorder. The program was also found to be cost effective and a “good value for money for public spending.”2 The intervention was most cost effective for children who had the greatest risk of developing conduct disorder. Benefits to parents’ mental health and the behaviour of siblings were also found.
* The article was published in March 2007 and therefore beyond the specified search dates for our own systematic review.
References:
1. Hutchings et al. 2007. Parenting intervention in Sure Start services for children at risk of developing conduct disorder: pragmatic randomized control trial. British Medical Journal, 334(7595), 678.
2. Edwards et al. 2007. Parenting programme for parents of children at risk of developing conduct disorder: cost effectiveness analysis. British Medical Journal, 334(7595), 682.
All programs also had a parental component. Both Early Impact and SAFEChildren used parent training which primarily involved teaching effective child management techniques including encouraging parental consistency, reinforcing appropriate behaviour and managing anger. SAFEChildren also focused on increasing parental support, engaging with schools and managing neighbourhood problems such as violence. In contrast, Early Risers used a family empowerment model which included appraising, planning and intervening with family problems.
The Early Impact program initially produced significant reductions in CD symptoms at school; however, these gains were not maintained at six-month follow-up. As well, the Early Impact program was ineffective in reducing CD symptoms in the home. The general effects of SAFEChildren were limited to academic skills and parental involvement with the school rather than symptoms of CD. Among the 20% of “high-risk children” and the 23% of children from “high-risk families,” program participation significantly reduced aggressive behaviours at six-month follow-up.
Similarly, among “severely aggressive children” with high levels of participation in the Early Risers program, there were significant reductions in teacher-rated disruptive behaviours at 12-month follow-up. Overall, however, Early Risers participants did not show significant reductions in disruptive behaviours. None of the programs were effective in reducing CD symptoms across all groups of children; however, the Early Risers and SAFEChildren programs produced the most solid long-term gains for high-risk children.
What we recommend
To most effectively and efficiently address disruptive behaviours, there needs to be a strong focus on prevention. Many of the known causes of children’s behaviour problems, such as parenting difficulties, can be addressed through prevention programs. There are common elements in the most effective prevention programs. They start early rather than waiting until problems are entrenched. They target high-risk families and attempt to intervene at family and community levels rather than just with the individual child. Their program contents focus on parent training and early child education including social skills training. As well as effectively preventing significant behaviour problems, interventions such as The Incredible Years are also cost-effective in “real world” community settings.6 Based on the strong research findings from this and our previous reviews, we recommend using prevention programs modeled after the characteristics of the most promising programs, namely Fast Track, Perry Preschool, John Hopkins, Nurse Home Visitation and The Incredible Years.
Treatment for clinically significant disruptive behaviours is nevertheless vitally important when prevention has not been possible. For children with CD, treatment should be modeled after the most promising programs including: The Incredible Years; Behavioural Parent Training; Parent Training; and Multidimensional Treatment Foster Care. (MST is discussed in our next article.) These interventions address behaviour concerns within the broader social contexts where they occur and focus on reducing factors that play a role in the development and continuation of behaviour problems such as parenting difficulties. Overall, by making early investments in effective prevention and treatment interventions, the benefits to children, families and society can be maximized.
References:
1. Waddell et al. 2004. Preventing and treating conduct disorder in children and youth. Vancouver, BC: UBC.
2. Larmar et al. 2006. Successes and challenges in preventing conduct problems in Australian preschool-aged children through the Early Impact (EI) Program. Behaviour Change, 23(2), 121-137.
3. Tolan et al. 2004. Supporting families in a high-risk setting: proximal effects of the SAFEChildren prevention intervention. Journal of Consulting and Clinical Psychology, 72(5), 855-869.
4. August et al. 2003. Dissemination of an evidence-based prevention innovation for aggressive children living in culturally diverse, urban neighborhood: The Early Risers effectiveness study. Prevention Science, 4(4), 271-286.
5. August et al. 2004. Maintenance effects of an evidence-based prevention innovation for aggressive children living in culturally diverse urban neighborhood: The Early Risers effectiveness study. Journal of Emotional and Behavioral Disorders, 12(4), 194-205.
6. Edwards et al. 2007. Parenting programme for parents of children at risk of developing conduct disorder: cost effectiveness analysis. British Medical Journal, 334(7595), 682.