1 The Prevention, Treatment and Management of Conduct Problems in Childhood and Adolescence David M Fergusson Christchurch Health & Development Study Department of Psychological Medicine University of Otago, Christchurch February 2013

2 Introduction In this talk I will attempt three tasks: A brief overview of evidence of the linkages between conduct problems in childhood and subsequent developmental outcomes An overview of the evidence of effective programmes for preventing and treating childhood conduct problems An examination of the translation of this evidence in the development of New Zealand policy.

3 The Christchurch Health and Development Study The Christchurch Health and Development Study (CHDS) is a longitudinal study of a birth cohort of 1265 children born in Christchurch, New Zealand. This cohort has been studied at birth, 4 months, 1 year, annual intervals to 16, and at 18, 21, 25 and 30 (a total of 22 occasions). As part of this research, extensive data was gathered on childhood behavioural adjustment and outcomes in young adulthood.

4 Summary of Key Research Findings Data from the Christchurch Health and Development Study was used to examine linkages between the development of conduct problems in middle childhood and later development to the age of 25. The study findings showed that early conduct problems were associated with significant increases in rates of: crime, arrest and imprisonment substance use anxiety/depression suicidal behaviour sexual risk taking

5 Major Conclusion These findings show the pervasive effects of early conduct problems on later development. It may be argued, plausibly, that no other common childhood condition has such pervasive and far reaching consequences for later development, as childhood conduct disorders.

6 Development of a Policy Response In response to the evidence from the CHDS and similar evidence from the Dunedin Multidisciplinary Health and Development Study (DMHDS), the NZ government convened an expert panel to provide advice on the prevention, treatment and management of childhood conduct problems. This group – the Advisory Group on Conduct Problems (AGCP) – comprised consultants from Life Course Research, Education and Psychiatry.

7 The Work of the AGCP The AGCP has been in operation for over three years. Key tasks have involved: Reviewing the literature to identify evidence based interventions Making policy recommendations Providing assistance with programme implementation Developing research designs to evaluate policy changes

Promising/Recommended Programmes for 3-7 Year Olds 8 8 Programme TypeTier(s) Family Based Interventions Parent Behaviour Management Training: PMTO; Triple P; Incredible Years; PCIT 1, 2, 3 School Based Interventions School-Wide Behaviour Support1, 2, 3 Teacher Behaviour Management Training: Incredible Years Teacher 1, 2 Good Behaviour Game1 Residential Multi-dimensional Treatment Foster Care (MTFC)3

Promising/Recommended Programmes for 8-12 Year Olds 9 9 Programme TypeTier(s) Family Based Interventions Parent Behaviour Management Training1, 2, 3 School Based Interventions School-Wide Behaviour Support1, 2, 3 Teacher Behaviour Management Training1, 2 Good Behaviour Game1 Check, Connect, Expect2 Multimodal Multi-Systemic Therapy1 Coping Power; Stop Now and Plan2 Residential MTFC; Teaching Family Homes (TFM)3

Promising/Recommended Programmes for Year Olds 10 Programme TypeTier(s) Family Based Programmes Teen Triple P; Functional Family Therapy2 School Based Interventions School-Wide Behaviour Support1, 2, 3 Teach, Prevent, Reinforce2, 3 Check and Connect3 Group Contingency Management Programmes1, 2 Multimodal Multi-systemic Therapy; Aggression Replacement Therapy; Adolescent Transitions Programme 3 Residential MTFC; TFM3

11 Overview of Promising/ Recommended Approaches Age Programme Type Parent Behaviour Management Training School-Wide Positive Behaviour Support Teacher Behaviour Management Training ? Group Contingency Management Multimodal Programmes– Residential Programmes

12 Common Features of Successful Interventions All take a problem-solving rather than a punitive focus All are founded in behavioural psychology, including social learning therapy, cognitive behavioural theory and related approaches All are manualised and can be transferred to new settings The majority have been developed in university settings rather than by service providers

13 What is Not on the List Wilderness Programmes Military Style Training (Boot Camps) Mentoring Restorative Justice

14 Policy Outputs The work of the AGCP has underwritten the development of the Positive Behaviour for Learning (PB4L) policy announced by the Ministry of Education in PB4L is centred around the implementation and evaluation of three of the programmes recommended by the AGCP: The Incredible Years Basic Parent Programme The Incredible Years Teacher Training Programme School-Wide Positive Behaviour Support

15 Policy Implementation To introduce these programmes to the Education sector, the Ministry then held a series of meetings throughout New Zealand to introduce teachers, health workers and social workers to the reasoning underlying PB4L and the evidence supporting the programme choices. These meetings were well attended with over 1000 participants in 12 centres, and very well received by the sector. This effort laid the groundwork for the implementation of PB4L.

16 Programme Implementation By 2014, PB4L intends to deliver: School Wide Positive Behaviour Support to 400 NZ Schools Incredible Years Basic Parent Programme to 12,000 parents Incredible Years Teacher Programme to 5,000 teachers This represents a very large investment in evidence based services within the education sector.

17 Evaluation The reports of the AGCP have emphasised the need for thorough evaluation of programmes before they are widely implemented. The Ministries involved have been responsive to this view and a research unit has been set up in the Ministry of Social Development to evaluate evidence based programmes in this area. The first evaluation planned is a first phase assessment of the Incredible Years Basic Parent programme.

18 Evaluation of Incredible Years Parent Programme The evaluation planned involves: 150 families from three sites who will be studied at: baseline, mid programme, end of programme, and 3 months after programme completion At least 50 families will be Māori Assessments will be made of child behaviour, parenting practices and family functioning before, during and after the programme

19 Evaluation of Incredible Years Parent Programme These assessments will be supplemented by single subject studies of 30 families (10 per site) and client satisfaction studies. The overall aim will be to build up a clear picture of the changes that families display following the introduction of the programme and to compare these results with benchmarks derived from existing randomised trials.

20 Some Preliminary Results from the IYP Trial (1) MeasurePre Mean (SD) Post Mean (SD) dp Conduct Disorder28.5 (6.7)23.8 (4.7)-.71<.0001 Oppositional Defiant35.8 (7.2)27.9 (6.1)-1.09<.0001 ADHD33.6 (8.1)29.2 (8.2)-.54<.001 Self Control36.2 (7.5)43.6 (7.8)+.98<.0001 Anxiety/Withdrawal27.2 (6.0)24.6 (5.5)-.43<.001 Social Competence54.6 (9.9)61.9 (9.6)+.73<.0001 Pre/Post Comparisons on Child Behaviour Ratings

Some Preliminary Results of the IYP Trial (2) Overview of Single Subject Findings

Concluding Comments There is now abundant evidence on effective methods for treating and managing conduct problems in childhood. The major task ahead is that of translating this body of evidence into effective and well evaluated programmes. The New Zealand experience suggests that the success of this enterprise depends critically on the ability of public servants to accept, institute and evaluate evidence based programmes.