ARTICLES

Conduct disorder: Can it be prevented?

Bennett, Kathryn J, Offord, David R
Current Opinion in Psychiatry, 14(4), 2001.

Prevention initiatives for conduct disorder are attractive for many reasons.  First, the number of children and adolescents with conduct disorder is far greater than the resources available to assess and treat them.  Second, treatment programs for conduct disorder tend to have poor compliance rates, with as many as 50% of children and families opting out prematurely.  Children who undergo treatment may also face stigmatization, which can cause their behavior to worsen.  Finally, conduct disorder in childhood and early adolescence can lead to serious anti-social behavior, even criminal activity, in adulthood. Identifying which children are at increased risk for conduct disorder and designing and implementing effective prevention programs is therefore a top priority.

The article summarized here reviews prevention programs for children with conduct disorder in three age groups: under 5, 5-11, and 11 and older.

Programs for children under age 5

The reviewers found 3 major programs aimed at preventing anti-social behavior in preschool children.  The first was a program for poor black 3- and 4-year-old children involving a daily preschool and a weekly home visit.  The second was an intensive program for the children of poor, African-American mothers, beginning in the first year of life, incorporating a day-care centre, social services, medical care, home visits, parent groups, toy lending and individualized educational activities for use at home with school-age children.  The third was a prenatal and early childhood (up to age 2) nurse home visitation program.

Programs for children aged 5-11

Four types of programs were reviewed, most of which were offered in school settings:

Single-factor approaches included programs that rewarded children for good behavior in the classroom, a program using peers to mediate playground conflicts, and a social skills program called “Second Step”.

Multicomponent approaches involved programs targeted to more than one risk factor, for instance, poor social skills and poor parenting, or poor social, reading and parenting skills. One program, called “FAST Track” addressed several risk and protective factors for conduct problems at multiple levels (child, family, school, peer group, community) with multiple interventions (academic skills, social skills, family support).

The competence-enhancement approach was evident in 2 programs: a social development project involving teacher training in classroom management, child social skills development (Grade 1) and drug resistance skills (Grade 6), and parent training to promote social competence; and a social competence promotion program for young adolescents.

Finally, one program used a school development approach using a planning and management team, a mental health team and a parent program to modify and improve school climate.

Programs for children older than 11

These programs focused less on prevention and more on treating established cases of conduct disorder. One of these, PATHE (Positive Action Through Holistic Education), concentrated on producing school-wide changes and enhancing services to high-risk children.  A second program, in which 11-year-old boys were randomly selected to receive regular contact with a social worker, showed very poor results in followup.

Results:

• All 3 programs in the under age 5 group showed positive results, although the intensive program measured only IQ and school achievement, not reduction in anti-social behavior.  The other two programs showed impressive long-term results, including lower rates of arrest, convictions and violations of probation, running away and alcohol consumption.
• In the 5-11 age group, the single-component approaches were less likely to have a major impact on reducing the incidence and severity of conduct disorder.  Other approaches were more encouraging but were hampered by high cost and difficult implementation.
• For children older than 11, only PATHE showed any positive results, with students reporting fewer delinquent acts and lower rates of drug use and school suspensions.  The second program, involving regular contact with a social worker, actually proved to be harmful for the boys in the treatment group, who had worse outcomes (death before age 35, criminality, psychiatric disorder) than those in the control group. 

Conclusions:

• The most encouraging results appear to occur when the prevention program is implemented in young children, has many elements, is intensive, and the target population is severely disadvantaged.
• Most of the successful interventions were carried out by highly skilled, highly motivated staff, and with rich resources.
• It is not known whether the same results would be obtained in a less disadvantaged population or under less than ideal conditions.
• Programs with encouraging results in the areas of competence enhancement and school-wide reform need to be evaluated more rigorously.
• Prevention programs that are found to be effective will have to be reasonably priced if they are to be replicated widely.