Children's Mental Health Research Quarterly

Prepared for Child and Youth Mental Health - British Columbia Ministry of Children and Family Development

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IN COMMENTARY
Disruptive behaviours: The numbers, the causes and the costs of not intervening

Mental health –– or social and emotional wellbeing –– is central for healthy development in all children, and vital for all children to thrive and become healthy adults. Behaviour is an important part of social and emotional wellbeing, although behaviour challenges occur with most children from time to time. Disruptive behaviours can vary dramatically in severity. Some challenging behaviour may be typical to a developmental stage, such as when a three-year-old experiences a temper tantrum in a grocery store. However, when behaviours become particularly serious and persistent and cause significant impairment in children’s functioning, there may be a clinically significant mental health problem such as conduct disorder (CD).

A child may be diagnosed with CD if he or she engages in repetitive and persistent violation of social rules including: aggression causing harm to people, animals or property; significant theft; or serious rule violations such as truancy or running away. Such serious and persistent disruptive behaviour problems usually suggest there are underlying causal factors that need to be addressed to help children to experience less distress and to function better at home, at school and in the community.

We have received many questions from policy-makers, practitioners and parents about disruptive behaviours in children. Here we respond to some of these questions.

Disruptive behaviours are common. Among children aged 4 to 17 years, an estimated 4.2% (or approximately 4 in 100 children) have severe behaviour concerns warranting a clinical diagnosis of CD.¹ This means that at any given time an estimated 29,000 children in BC are affected, making CD the third most common mental disorder among children. If milder behaviour problems are considered, many more than 29,000 children are likely affected. Conduct-related problems are the most common reason for children to be referred to mental health services in school and community settings.² Also, many other mental health problems (including anxiety, learning disorders, depression and psychosis) often first present as disruptive behaviour.³

Most important risk factors involve variables beyond the level of the individual child

Given the large numbers of children experiencing clinically significant behaviour problems, it is not surprising that parents, foster parents, teachers and practitioners frequently identify a need for intervention. Perhaps most importantly, children with severe behaviour problems need to receive early interventions because without these their problems frequently persist, leading to distress and impairment throughout adulthood.⁴

What causes disruptive behaviours?

Disruptive behaviours are likely caused by a web of interacting factors affecting children, families and the broader community environment.⁵ Known determinants are highlighted in the table below. These factors are interrelated and the relative importance of each can vary during different developmental periods. Notably, most important risk factors involve variables beyond the level of the individual child. For example, when children experience inconsistent nurturing or are exposed to harsh discipline, they are much more likely to exhibit their distress through behaviour problems.

Determinants of Disruptive Behaviours

Protective Factors6,7
Long-term support from at least one consistent care-giving adult Good learning abilities Good social skills	Easy temperament Few siblings Sense of skill or competency Positive beliefs about the larger world
Risk Factors5
Child Factors Irritable or difficult temperament Impulsivity and attention problem Early physical fighting Learning difficulties	Family Factors Low parental engagement and monitoring Parental hostility Harsh discipline Young maternal age Maternal smoking	Social Factors Peer rejection Negative experiences leading to negative thought patterns Isolation with deviant peers Absence of healthy school and community programs Absence of healthy and consistent long-term adult support

To be most effective, interventions need to reduce risk factors and enhance protective factors –– in other words, to address the underlying causes of children’s behaviour problems and create environments that enable more children to thrive.

Preventing just one case of CD can save an estimated $1.7 million in cumulative lifetime costs

What are the costs associated with disruptive behaviours?

Severe problems like CD are associated with distress for children and with significant costs for society. When children’s behaviour problems are not addressed early, there are significant costs associated with then providing many necessary services including: mental health; child protection; special education; and youth justice. Because of the multiple sectors involved, preventing just one case of CD has been estimated save an estimated $1.7 million in cumulative lifetime costs.⁸ Most importantly, children cannot go on to meet their full potential when behaviour problems interfere with their development and functioning. In addition to helping more children thrive, public investments are likely enhanced if resources are deployed “upstream” by addressing the underlying causes and preventing problems before they arise, rather than waiting until problems are entrenched.² Fortunately, many of the situations leading to children developing serious behaviour problems are preventable, as we outline in the next article.

IN REVIEW
Addressing disruptive behaviours

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 (Australia)	4-5	Child SST delivered by teachers & behavioral consultants in schools & group PT delivered by clinicians in school & homes	Universal SST: 10 wks intensive (+ 6 mos extended phase) PT: 3 2-hr sessions	No significant symptom or diagnostic reductions at 6-mo follow-up
SAFEChildren3 (USA)	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 (USA)	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.

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.

IN FOCUS
The latest evidence on Multi-Systemic Therapy (MST)

What is MST?

MST is a family-based treatment for children with significant behaviour, emotional and social problems. It is designed to address known determinants of children’s behaviour problems at the individual, family and community levels. Master- and doctoral-level therapists, with small caseloads, are available to program participants 24 hours a day during treatment which typically lasts four to six months. MST is a home-based intervention intended to facilitate access to services and to promote using new skills in children’s natural environments.

Treatment is individualized to the specific needs of children and families. MST begins with family members identifying goals. Interventions are then designed collaboratively with input from the MST therapist and family members. Therapeutic modalities are adapted and integrated from treatments with empirical support including strategic family therapy, structural family therapy, behavioural parent training and cognitive-behavioural therapy. Parents are assisted in developing increased family structure and in using natural reinforcers to improve behaviour. Children are encouraged to decrease involvement with delinquent peers and to increase association with prosocial peers. Family empowerment is emphasized and the use of natural child, family and community resources is encouraged.

It will be crucial to carefully evaluate any new implementations of MST in Canadian settings

Examining the studies

Littell, Popa and Forsythe1 recently published a systematic review of licensed MST programs. Applying rigorous (Cochrane) methodological standards, the authors accepted eight studies in their review, all RCTs.¹ Participants included children between the ages of 10 and 17 with all but one study focusing on children engaging in disruptive behaviours. Characteristics of participants and interventions are described in the table below. All participants were high-risk.

¹ The included studies were conducted between 1985 and January 2003 and were therefore beyond the specified dates for inclusion in our own In Review article.

Characteristics of Study Participants & MST Interventions

Study	Targeted Sample (Country)	Sex	Ethnicity	MST duration	Comparison Group (direct contact hrs)
Borduin 1990	Juvenile sex offenders (US)	100% male	38% AA 62% C	37 hours	Individual therapy (45)
Borduin 1995	Juvenile sex offenders (US)	68% male	30% AA 70% C	23 hours	Individual therapy (28)
Henggeler 1992	Juvenile sex offenders (US)	77% male	56% AA 42% C	33 hours	Usual probation services (--)
Henggeler 1997	Juvenile sex offenders (US)	82% male	81% AA 19% C	117-123 days	Usual probation services (--)
Henggeler 1999a	Juvenile sex offenders (US)	79% male	50% AA 47% C	40 hours	Usual probation services* (--)
Henggeler 1999b	Juvenile sex offenders (US)	65% male	65% AA	92 hours	Psychiatric hospitalization (--)
Leschied 2002	Juvenile offenders (Canada)	74% male	13% Aboriginal	34 sessions	Usual probation services (--)
Ogden 2004	Children with behaviour problems† (Norway)	65% male	--	--	Usual child welfare services (--)

AA = African American | C = Caucasian | -- = not reported
* 22% of children received substance use &/or other mental health services
† including emotional disturbance, substance abuse, criminal offences, harm to self/others, domestic violence

MST produced inconclusive results

Mixed results were found in the eight studies examining the effectiveness of MST. In five of the studies (conducted in the US), MST significantly reduced at least one measure of disruptive behaviour including incarceration rates and length, arrests, self-reported delinquency or externalizing behaviours. As well, in three of these studies (Borduin 1990, 1995; Henggeler, 1992) all measures related to disruptive behaviour significantly favoured MST (even if findings were not statistically significant). In contrast, in the one Canadian study , done in Ontario, there were no significant differences in disruptive behaviour outcomes between the MST and usual services groups. In addition, when the data from all studies were combined, MST was no more effective than usual services for any variables related to disruptive behaviours.

Because of methodological limitations, including limited statistical power (making it difficult to detect significant group differences), the authors could only conclude that MST is not consistently more effective than usual services. MST was still recognized as having several advantages including: comprehensive services; strong theoretical foundation; and no evidence of any harmful effects. The review authors also commented on the possible reasons for MST not being more effective than usual services in Canadian children. Canadian ‘s usual health, social and educational services for children were identified as being relatively more extensive and robust than services in the US. Given these findings, it will be crucial to carefully evaluate any new implementations of MST in Canadian settings.

IN PRACTICE
Applying the research evidence

We recently spoke with Barry Fulton of CYMH with MCFD to discuss his experiences using “evidence-informed practices” in providing services to children with disruptive behaviours. Barry is Social Worker and CYMH Manager for Transitional Services within the Okanagan Region.

Barry recounted the changes he has experienced during his 27 years of helping children with behaviour problems. He described the frustration experienced by many practitioners when they used interventions that did not produce expected results, such as “scared straight programs”. Scared straight programs have been used within some juvenile justice systems. Such programs typically involve trying to stop a child’s disruptive behaviours by attempting to evoke fear of the possible negative outcomes. Examples have included touring youth through jail facilities and morgues.

In contrast, Barry noted the shift to using “evidence-informed practices” has produced some very positive results. He described being drawn to these interventions because they gave him the necessary confidence in the effectiveness of his work –– especially over the long-term. Many of the empirically-based interventions also make sense on a personal level for Barry as a parent. He described programs that include a parenting component as enabling “parents and children to get closer together.”

The shift to using “evidence-informed practices” has produced some very positive results

He added that it is vital to be systematic in addressing behaviour problems if we are to be effective. For example, it has been critical in his work to develop partnerships with those organizations frequently involved in the lives of children with disruptive behaviours including the schools and child protection and youth justice agencies. To ensure a greater chance of success, Barry highlighted the importance of “moving it out of the office and into the community and homes.”

About the Children’s Health Policy Centre

We are a research group in the Faculty of Health Sciences at Simon Fraser University. Our work focuses on integrating research and policy to improve children’s social and emotional wellbeing, or children’s mental health. Our work complements the mission of the Faculty of Health Sciences to integrate research and policy for population and public health locally, nationally and globally.

Public Health Strategy for Children’s Mental Health

About the Quarterly

The Children’s Mental Health Research Quarterly is an electronic publication prepared for Child and Youth Mental Health at the British Columbia Ministry of Children and Family Development. The Quarterly represents a continuation of our six-year research-policy partnership with the Ministry. The purpose of the Quarterly is to provide regular research updates on the best currently available research evidence in children’s mental health.

Please visit www.childhealthpolicy.sfu.ca to learn more about our ongoing work integrating research and policy to improve children's social and emotional wellbeing.

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