Children with Conduct Problems: Prevention and

Intervention

Stephen ScottInstitute of Psychiatry, King’s College London

Suomi, 7 November 2014

Conduct Disorders (ODD & CD)Early antisocial behaviour is hugely predictive of later poor function

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)

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)

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%

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 £

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

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

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

Brain in conduct disorderRubia, Scott, Taylor et al (2008). Am J Psychiatry

Sustained Attention

RewardCD < C, ADHD

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

“Cold CD” - CU traits

Callous – unemotional style Lacking empathy Lacking guilt Unkind Predatory aggression

Still from LeRoy’s “The Bad Seed” (1956)

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

Eye Gaze Hotspots

“Cold’ conduct problems

Healthy boys Hi CU boys

Dadds et al. (2008) J Amer Acad Child Adolesc Psych.

Child-only interventions can improve conduct problems Anger mangement; Social skills training (eg

Webster-Stratton) Stimulant medication when there is comorbid

ADHD

ThinkThink

Feel Do

Individual intervention for conduct problems

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

Antisocial Behaviour Before and after intervention

(percentile level; p<0.0001; Scott et al., 2001)

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

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

Antisocial Personality: Prevention

Evidence from two controlled trials:

a) clinical trial (BMJ) b) community sample (‘SPOKES’)

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

Parenting effects

• No effect on Alabama qu’re, Parent or Child

• No effect on directly observed parent-youth

interaction (Oregon “hot topics”)

ODD diagnosis rateat 8 year follow-up (p< 0.007; Scott et al., 2014 )

Parent SDQ total(p<0.003)

Youth report home beh(p<0.038)

Reading score (WORD)

(p< 0.03)

Youth report school beh(ns)

Teacher SDQ total(ns)

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)

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

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)

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

Child Antisocial Child Antisocial Behaviour - Behaviour - PACS Interview scores PACS Interview scores

0.8

0.9

1

1.1

1.2

Pre Post

GroupHelpline

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

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

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?

Reading Video

Effect-size of change in antisocial behaviour vs controls (PACS parent interview)all interventions significant at both times

Effect-size of change in reading vs controls (BAS test)

IY significant at 1 and 2 years, Lit & Combi not

“An ounce of action is worth a ton of theory”

Friedrich Engels, 1860

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

‘… 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

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

TRAINER

PARENTINGPRACTITIONER

PARENT

CHILD

Feedback loops of research contribution

-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)

Skill in Functional Family Therapy & crime rates

© 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