1. The Promise of Prevention for Conduct Problems in At-risk Youth: Findings from the Fast Track Project Bob McMahon Department of Psychology University of Washington April 19, 2010

2. FAST TRACK  Developmental Model  Research Design  Intervention Model  Findings

3. “EARLY STARTER” DEVELOPMENTAL PATHWAY  Preschool/Early School-Age Onset  Overt and Covert Behaviors  High Degree of Continuity  Poor Prognosis  Enormous Societal Cost “ Career Criminal” = $1.3 million (Cohen, 1998)

4. “EARLY STARTER” PATHWAY TO ANTISOCIAL BEHAVIOR Preschool Years Early Education Years Early Education Years Early Adolescence Early child, family, and community risk factors Poor school readiness in cognitive, social, and emotional domains Academic failure Peer rejection Social coping deficits Adult support/ supervision Academic failure Peer rejection Social coping deficits Adult support/ supervision Deviant peers Poor adult monitoring Alienation/ depression Deviant peers Poor adult monitoring Alienation/ depression Increased and Diversified Antisocial Behavior School Entry

5. Preschool Years Elementary and Middle School Years Adulthood Adolescence Serious antisocial activity School drop-out and failure Substance use Early/risky sexual activity Comorbid psychiatric disorders DEVELOPMENTAL MODEL

6. Preschool Years Elementary and Middle School Years Adolescence Adulthood Psychological problems Criminal behavior Poor educ/occup adjustment Marital disruption Increased mortality DEVELOPMENTAL MODEL

7. IMPLICATIONS OF THE DEVELOPMENTAL MODEL FOR INTERVENTION DESIGN  Multiple Skill Domains  Multiple Socialization Support Systems  Sustained, Well-Integrated  Developmentally and Culturally Informed

8. FAST TRACK  Developmental Model  Research Design  Intervention Model  Findings

9. The Fast Track Project Conduct Problems Prevention Research Group Robert J. McMahon University of Washington Karen L. Bierman Mark T. Greenberg Pennsylvania State University Kenneth A. Dodge John D. Coie Duke University Ellen E. Pinderhughes Tufts University John E. Lochman University of Alabama

10. FAST TRACK FUNDING  Fast Track is funded by: National Institute of Mental Health  With additional support from: National Institute on Drug Abuse Department of Education Center for Substance Abuse Prevention

11. FAST TRACK SITES Seattle, WA Nashville, TN Durham, NC Rural, PA

12. School-Entry Transition Continuing Support Middle School Transition Continuing Support FAST TRACK TIMELINE YEAR (1991-1993) Screening Implementation Outcome/Mediators INTERVENTION (2005-2007) ASSESSMENT Current Age of Sample GradeKg1-3 4-56-78-910 11-1220 22 AGE

13. SCREENING AND SELECTION Teacher Screen9,594 (54 schools, 3 years)  Eligible - Parent Screen 3,600 (Top 38%)  Parent Screen 3,267 (91%) Total Screen Score (T+P)1,027  Grade 1 at Core School 968 (94%)  High Risk Sample 891 (92%) Control 446 Intervention 445

14. SAMPLE (4 SITES AND 3 COHORTS)  High-Risk (n = 891)  445 Intervention/446 Control  Random Assignment by School  47% Caucasian, 51% African-American, 3% Other  69% Boys, 31% Girls  Normative Community Comparisons (n = 387)

15. MULTIPROBLEM ASPECTS OF HIGH-RISK SAMPLE  Family Context Single Parent/Inappropriate Partner Family Conflict/Violence Substance Abuse Personal Adjustment Problems “Insular” Economically Disadvantaged  Neighborhood Context High-Risk, Unsafe Neighborhoods

16. ASSESSMENT MODEL  Annual Assessments  Multiple Informants Parent, Teacher, Youth, Peers  Multiple Methods Ratings, Direct Observations, Achievement Tests, Psychiatric Interviews, Sociometrics, School Records, Court Records  Standard Measures Shared with Other National Studies CBC/TRF/YSR, National Youth Survey, C-DISC-4, SACA

17. FAST TRACK  Developmental Model  Research Design  Intervention Model  Findings

18.  Elementary-School Phase –School-Entry Transition (Grades 1 - 2) –Maintenance and Support (Grades 3 - 5)  Adolescent Phase –Middle School Transition (Grades 5 - 7) –Maintenance and Support (Grades 8 - 10) PHASES OF INTERVENTION

19. AREAS OF INTERVENTION (Elementary School Phase) Academic Achievement Child Coping/ Problem Solving Home-School Partnership Peer Relations Parenting & Socialization Classroom Atmosphere

20. INTERVENTION COMPONENTS (Elementary School Phase) Family Enrichment Program School

21. INTERVENTION COMPONENTS (Elementary School Phase) Family Enrichment Program School PATHS

22. INTERVENTION COMPONENTS (Elementary School Phase) Family Home Visiting Enrichment Program Parent Groups Friendship Groups Parent-Child Sharing Time School PATHS Tutoring Peer Pairing

23. STAFFING RESPONSIBILITIES (Elementary School Phase)  FAMILY COORDINATOR (FC) Conducts Parent Groups, Parent-Child Sharing Time, Home Visits  EDUCATIONAL COORDINATOR (EC) Conducts Friendship Groups Consults with Teachers Supervises Tutors  CLASSROOM TEACHER Teaches PATHS Lessons  TUTOR Conducts Reading Tutoring and Peer Pairing

24. IMPLEMENTATION ISSUES (Elementary School Phase)  Attendance Flexible Group Times Familiar Location Transportation Child Care Parents Are Paid Staff Members Ethnically-Matched Staff Social Support Among Group Members

25. STRUCTURE OF ADOLESCENT PREVENTIVE INTERVENTIONS  Standard Interventions (Grades 5-8)  Individualized Interventions (Grades 5-10)

26.  Standard Interventions (Grades 5-8) All Youth/Families Monthly Curriculum-Based Parent/Youth Groups Normative Challenges of Adolescence Middle/H.S. Transition Support Individualized Interventions (Grades 5-10) STRUCTURE OF ADOLESCENT PREVENTIVE INTERVENTIONS

27.  Standard Interventions (Grades 5-8)  Individualized Interventions (Grades 5- 10) Assessment of Risk/Protective Factors Individualized Skill-Building and Support Services STRUCTURE OF ADOLESCENT PREVENTIVE INTERVENTIONS

28. STAFFING RESPONSIBILITIES (Adolescent Phase)  YOUTH COORDINATOR (YC) Individualized, Criterion-Based Prevention Services Curriculum-Based Youth and Parent Groups Home Visits  VOCATIONAL COORDINATOR Arrange Workshops/Field Trips/Job Shadows  MENTOR One-on-One Recreational Activities with Youth  TUTOR Conducts Academic Tutoring

29. FAST TRACK  Developmental Model  Research Design  Intervention Model  Findings

30. RESEARCH PARTICIPATION - SAMPLE x SITE (% IN YEAR 11)

31. DID STRATEGIES WORK? PARTICIPATION IN PARENT AND CHILD GROUP

33. INTERVENTION EFFECTS Data Analytic Strategy  “Intent To Intervene” Model “Once Randomized, Always Analyzed” Regardless of Extent to Which Families Participated in Intervention, Considered Part of Intervention Sample for Analyses

34. KEY QUESTIONS  Does Fast Track Work?  How Does It Work?  Does It Work Equally Well for Everyone?  How Much Does It Cost?

35.  Modest Intervention Effects in Multiple Domains Through Elementary School Both high-risk (and universal) samples Effect sizes strongest following initial intensive prevention efforts Small to moderate effect sizes maintained with sustained prevention support DOES FAST TRACK WORK? Elementary School (Grades 1-5)

36.  Classroom-level Analyses  Peer Sociometrics Aggression, activity-disruption  Classroom Atmosphere  Prediction of Outcome Quality of teacher implementation Dosage (# of lessons) not strong predictor DOES FAST TRACK WORK? PATHS Universal Intervention End of Grade 1 CPPRG (1999b)

37.  Youth present throughout Grades 1,2, and 3 (n=2,937)  Aggression (T,P), Academic Engagement (T), Social Competence (T), Hyperactive/ disruptive (P)  Teacher Ratings Moderated by School Environment Stronger in less disadvantaged schools ↑ baseline aggression – ↑ effects on aggression  Peer Ratings Moderated by Gender Effects limited to boys DOES FAST TRACK WORK? PATHS Universal Intervention End of Grade 3 CPPRG (2010)

38. DOES FAST TRACK WORK? Middle School  Do Not Find the Broad Effects on Aggressive and Externalizing Behavior Seen in Elementary School  Lower Levels of Hyperactive Behaviors (Behavioral Inhibition) at Grade 7  More Deviant Peer Involvement in Grades 7 and 8 CPPRG (in press)

39. KEY QUESTIONS  Does Fast Track Work?  How Does It Work?  Does It Work Equally Well for Everyone?  How Much Does It Cost?

40. HOW DOES IT WORK?  “ Domain-Specific ” Effects

41. MEDIATION OF GRADE 4 OUTCOMES CPPRG (2002d) Grade 3 Mediators Grade 4 Outcomes Home Parenting Behavior Change Aggressive/Oppositional Behavior School Authority Acceptance Peer Social Preference Problems/Prosocial Behavior Change Social Cognition Hostile Attributions Association with Substance Using Peers (p<.10)

42. HOW DOES IT WORK?  “Domain-Specific” Effects  Must Address Each Setting in Which the Child Lives  Suggests Importance of Multicomponent Intervention

43. KEY QUESTIONS  Does Fast Track Work?  How Does It Work?  Does It Work Equally Well for Everyone?  How Much Does It Cost?

44.  Works Comparably for: Boys and girls European- and African-American children Urban and rural communities DOES IT WORK EQUALLY WELL FOR EVERYONE? Elementary School

45.  No Consistent Moderation by: Demographics - gender, race, site, cohort Child variables - IQ Family variables - marital status, SES, parent mental health/substance use Neighborhood variables - poverty, instability, quality

46.  HOWEVER – By Grade 9, Effects Depend on Child ’ s Severity of Risk as Measured 10 Years Earlier During Kindergarten! DOES IT WORK EQUALLY WELL FOR EVERYONE? Antisocial Behavior

47.  Highest-Risk Youth ( top 3% at Kindergarten ) Much Less Likely To: Have an externalizing disorder diagnosis - Oppositional defiant disorder, conduct disorder, attention deficit-hyperactivity disorder (ADHD) Engage in self-reported antisocial behavior  No Intervention Effect for Moderate-Risk Youth DOES IT WORK EQUALLY WELL FOR EVERYONE? Antisocial Behavior in Grade 9 CPPRG, 2007

48. INTERVENTION EFFECTS Grade 9 DISC Diagnosis of Conduct Disorder (CPPRG, 2007) *p<.05 (Intervention x Risk Level) 0.04

49. INTERVENTION EFFECTS Grade 9 DISC Diagnosis of “Any” Externalizing Disorder (CPPRG, 2007) *p<.05 (Intervention x Risk Level) 0.13

50. INTERVENTION EFFECTS Grade 9 Self-Reported Antisocial Behavior (CPPRG, 2007) *p<.05 ( Intervention x Risk Level) 1.66

51. INTERVENTION EFFECTS Lifetime Prevalence of Conduct Disorder (through Grade 12) 0.12 CPPRG (in press)

52. YOUTH ARRESTS  Court Record Data Collected Annually 6 th grade – age 19 Juvenile and adult court records  Searched County of Residence and Surrounding Counties  Lifetime Severity Weighted Frequency Juvenile arrests Adult arrests Self-reported delinquency CPPRG (in press)

53. ARREST RECORD OUTCOMES  Juvenile Arrests Court-recorded: odds = 71% of odds for controls Moderate-severity arrests: 76% rate of controls Onset of arrest: odds = 77% of controls CPPRG (in press)

54. ARREST RECORD OUTCOMES  High-Severity Self-reported Delinquent Behavior Onset: odds = 82% of controls  High-Severity Adult Arrests Frequency: Highest-risk youth – 47% fewer arrests compared to controls Onset: Effects for ¾ sites; iatrogenic for Nashville CPPRG (in press)

55. KEY QUESTIONS  Does Fast Track Work?  How Does It Work?  Does It Work Equally Well for Everyone?  How Much Does It Cost?

56. HOW MUCH DOES IT COST?  Each Chronic Criminal Costs Society >$1.3 Million (Cohen, 1998)  Fast Track Costs About $5,800/Year Per Child ($58,000 Total)  Cost-Effective for Highest-Risk Children (Top 10%) Conduct disorder diagnosis Index crimes Foster et al. (2006)

57. COST SAVINGS DUE TO INTERVENTION (PER CHILD) Low 90% Top 5-10% Top 5%

58.  Parent and youth report (SACA; Grades 9-12)  General Health ServicesOdds Ratio General health provider.77 Pediatrician.78 Emergency department.78 Gen health provider-Mental health.64  Mental Health Services Outpatient MH services (Gr 11-12).52 Inpatient MH services NS DOES FAST TRACK WORK? Health Services Use Grades 9-12 Jones et al (2010)

59.  Modest Intervention Effects in Multiple Domains Through Elementary School Both high-risk and universal samples Effect sizes strongest following initial intensive prevention efforts Small to moderate effect sizes maintained with sustained prevention support  In Contrast to Elementary School, Minimal Intervention Effects in Middle School SUMMARY

60.  Mediation Analyses Indicate Domain- Specific Effects Suggests importance of multicomponent intervention  Effects Generalizable Across Gender, Ethnicity, Site, Etc. During Elementary and Middle School SUMMARY (cont.)

61.  However, During High School, Emerging Moderation of Effects Based on Severity of Initial Risk for Some Outcomes  Strong Intervention Effects on Conduct Disorder Diagnosis Through Grade 12 for Highest-Risk Youth  Strong Intervention Effect for Juvenile Arrests SUMMARY (cont.)

62.  Although Expensive, Fast Track is Cost- Effective for Most At-Risk Youth  Not Only in Terms of ↓ Dx of Externalizing Disorders, But ↓ Use of General Health and Outpatient MH Services During Adolescence (Jones et al., 2010) SUMMARY (cont.)

63. CURRENT/FUTURE DIRECTIONS  Continued Analysis of Intervention Effects Through Age 20  Economic Analyses  Analysis of DNA/Identification of Candidate Marker Genes  Contact Sample at Age 25  Dissemination Efforts

64. CURRENT/FUTURE DIRECTIONS  ARRA Admin Supplement (Witkiewitz) Developmental pathways of conduct problems Role of callous-unemotional traits as predictor of youth outcomes and/or moderator of FT intervention  ARRA Challenge Grant (King, Witkiewitz) Identify Krueger’s “externalizing spectrum” in childhood and adolescence?

65. ADDITIONAL INFORMATION  Fast Track website: http://fasttrackproject.org  Contact: Bob McMahon Phone: (206) 685-9127 University of Washington FAX: (206) 685-3944 Department of Psychology Box 351525 Seattle, WA 98195-1525 Email: mcmahon@u.washington.edu