Church Report: The definition, diagnosis and treatment of children and youth with severe behaviour difficulties

Publication Details

This report is a review of the research into the development and treatment of severe behaviour difficulties in children and adolescents. The review was commissioned by the Ministry of Education, and was produced by John Church and team from the Education Department at the University of Canterbury.

Author(s): John Church and Education Department Team, University of Canterbury.

Date Published: 2003

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Executive Summary

This report reviews the results of research into the development and treatment of severe behaviour difficulties in children and adolescents. Because the time allowed for this review was quite limited, the review is tightly focused on the most prevalent type of behaviour difficulty, that is, the development and treatment of early onset antisocial behaviour difficulties in children who have the potential for normal development. Research into the treatment of children with behaviour difficulties arising from organic impairments (such as severe intellectual disabilities and autism) is not reviewed.

A review of research into the development of antisocial behaviour in children indicates that we now have a reasonably good understanding of the way in which antisocial development occurs. This research has identified both the learning processes which are involved and the contexts in which antisocial development occurs. The learning processes which need to be targeted by any intervention are the positive and negative reinforcement processes which teach, strengthen and maintain defiant, coercive and aggressive responses during interactions with other people. The contexts which need to be targeted are the child's antisocial interactions with parents and siblings (the home context), with teachers and classmates (the school context) and with peers and associates (the playground and recreational contexts). Detailed analyses of the interactions of antisocial children with their parents, teachers and peers suggest that children who are being raised in environments in which polite and friendly responses pay off more frequently than coercive and antisocial responses learn to interact with others in polite and friendly ways while children who are being raised in environments where coercive and antisocial responses pay off more frequently learn to interact with others in coercive and antisocial ways.

In order to prevent antisocial children growing up to become antisocial adults, it is desirable that such children be identified as early as possible and as soon as the first signs of antisocial development begin to appear. Our review of research into diagnostic screening procedures found that a wide variety of screening procedures were currently being used. The lack of a standardised screening procedure suitable for New Zealand use is currently hindering attempts (a) to estimate the number of children whose development is following an antisocial pathway, (b) to measure the proportion of these children who are being detected by current services and (c) to measure the cost effectiveness of the services which are being provided for these children at each age level. An evaluation of currently available screening instruments suggests that the Systematic Screening for Behavior Disorders procedure and the Early Screening Project procedure devised by Walker and his associates represent the current state of the art as far as diagnostic screening is concerned. Both could be adapted for use in New Zealand schools.

Three separate surveys involving all of the schools in two South Island provinces have estimated the proportion of antisocial children in New Zealand schools to be somewhere between 4.5 and 5.0 per cent. These same surveys show that the proportion of antisocial students in low decile schools is somewhere between 3 and 6 times greater than the percentage of antisocial students in high decile schools. The prevalence for Mäori and Pacific Island students is unknown. The numbers of antisocial children at age 8 and at age 11 were closely similar in two out of three of the prevalence studies which suggests that antisocial development, once established, was not being reversed by the kinds of interventions which New Zealand was providing for these children in the second half of the 1990s.

Our review of longitudinal studies of antisocial development suggests three main conclusions. First, the great majority of children who do not engage in antisocial behaviour during childhood do not engage in antisocial behaviour during adolescence and adulthood. Secondly, children identified during childhood as children who engage in high rates of antisocial behaviour are at considerable risk for a large number of adverse outcomes as adults. These adverse outcomes include unemployment, psychiatric disorders, alcoholism and other forms of substance abuse, early pregnancy and early fatherhood, drunk driving convictions and loss of licence, criminal offending, higher rates of domestic violence, separation and divorce, higher rates of injury and hospitalisation, and a shortened life expectancy. Thirdly, current social conditions appear to be producing a group of life-course persistent antisocial children who go on to become delinquent youth and then adult offenders. For boys raised in the 1970s, this group numbered about 7 per cent of all boys.

Research into diagnostic procedures suggests that Functional Assessment procedures are the preferred diagnostic procedure for identifying the factors which will need to be changed during any intervention. Functional assessment is a procedure which attempts to identify the environmental conditions (including the behaviours of other people) which are functioning to motivate continued use of antisocial (rather than prosocial) responses.

The research reviewed in this report suggests that children with severe antisocial behaviour difficulties are likely to have four major types of special teaching needs. These are (a) the need to practise responding in prosocial (rather than antisocial) ways to the behaviour of other people, (b) the need to learn that other people can be trusted and that how other people react to one's behaviour is important and needs to be taken into account, (c) the need to learn and to practice age-appropriate social skills, especially those which are necessary for the development and maintenance of positive relationships with peers and with adults and (d) the need to catch up as quickly as possible with respect to missing academic skills, especially in reading, writing, and maths.

The research reviewed in this report shows that the task of halting antisocial development and accelerating social development becomes increasingly more complex, more costly, and less likely to succeed the older the child becomes. A number of studies have shown that, prior to school entry it is possible to halt antisocial development and accelerate prosocial development in 75% to 80% of antisocial children. Between the ages of 5 and 7 years, the success rate of the most effective interventions drops to 65-70%, and between the ages of 8 and 12 years the success rate for the most effective interventions falls to 45% to 50%. During adolescence, the most effective interventions succeed in rehabilitating only a small fraction of the children who were engaging in antisocial behaviour at school entry. This appears to be because (a) antisocial children acquire increasing numbers of increasingly sophisticated antisocial skills as they become older, (b) these antisocial responses and skills become increasingly entrenched and habitual the more they are practised and (c) the number of adults and peers that the child comes into daily contact with (and who would need to be involved in any intervention) keeps increasing the older the child becomes.

The research on antisocial development indicates that the first and primary aim of intervention work with antisocial children will usually be to reduce the frequency of punishment (for both inappropriate behaviour and academic failure) to a level comparable with that being experienced by normally developing age-mates - and to accomplish this as quickly as possible. This is because excessive punishment (and failure) is one of the main drivers of antisocial development.

During the pre-school and primary school years, contingency management procedures appear to be the most effective procedures for halting antisocial development and accelerating prosocial development. They also have the strongest research support. Contingency management procedures involve (a) the selection of specific behaviour change goals, (b) the teaching of any missing skills which the child needs in order to achieve the goal, (c) the identification of rewards (e.g. small privileges) which will provide the child with a strong motivation to achieve the goal, (d) the use of a small and predetermined penalty (such as a 3-minute time out or privilege loss) for antisocial behaviour and (e) the careful monitoring and recording of child achievements and antisocial responses from hour to hour. Because the reinforcing effects of different rewards are culturally relative it is important always to consult with the antisocial child and to get the child to select (from a list of available rewards) the particular reward which they would like to work for. It is also important to ensure that any rewards which will be earned are acceptable to the child's parents. Contingency management schemes which include both rewards for socially appropriate behaviour and a small penalty for antisocial behaviour motivate a more rapid transition to socially appropriate behaviour than schemes which provide only a reward for appropriate behaviour.

It seems extremely unlikely, on the basis of the research reviewed in this report, that antisocial development can be halted and prosocial development accelerated using just a school-based intervention on its own. This appears to be because children spend far less time in the classroom than they do outside the classroom and hence are exposed to fewer social learning opportunities in the classroom than they are exposed to in non-classroom settings.

The research into parenting skills training indicates that there are a number of training programmes which are effective in helping parents to halt antisocial development and to accelerate the social development of their children. The four parenting skills programmes which appear to be most effective are (a) the Oregon Social Learning Centre programme, (b) Webster-Stratton's video-based training programme, (c) the Australian Triple P courses and (d) the Forehand and McMahon programme. All of these programmes focus on helping parents to learn how to (a) monitor a child's whereabouts and behaviour, (b) participate actively in a child's life, (c) use encouragement, praise, and rewards to manage child behaviour at home, (d) ensure that discipline is fair, timely and appropriate to the misbehaviour, and (e) use effective, positive, conflict-resolution and problem-solving strategies. Parenting training courses have their strongest effects with the parents of young children and weaker effects with the parents of children over the age of 8 years. The effectiveness of parent training interventions is dependent in part upon the cultural competence of the parent educator who must be able to communicate with parents in their own language and who must be sufficiently trained and experienced to be able to establish a positive interpersonal relationship both with parents from a variety of different cultural backgrounds and with parents who are experiencing major problems in their personal lives. These are important requirements for parent educators who will be working with Mäori and Pacific Islands parents.

It is fairly clear from the intervention research that home and school interventions are more effective in halting antisocial development and accelerating prosocial development than interventions in the home only or the school only. Well designed home and school interventions, which reach the child before the age of 7, may succeed in returning the antisocial child to a normal developmental trajectory in 70 to 80 per cent of cases. The Early Social Learning Project and Project Early which ran in Christchurch in 1996-1997 have shown how this can be achieved in the New Zealand setting.

The research into intervention work with children aged 8 and over has repeatedly found that there are significant barriers to implementing effective interventions for older antisocial children. These include teacher ambivalence about whether they should be responsible for teaching children with severe antisocial behaviour problems and difficulties in implementing the kinds of curriculum changes, behaviour management schemes and monitoring procedures which are required for effective work with antisocial children at this level. There are also significant barriers to effective work with the parents of older antisocial children. Some parents are under such stress, or have such serious personal problems, that they are unable to fully meet their children's needs.

There is some evidence, albeit limited, in the research reviewed for this report that the effectiveness of home and school interventions for older antisocial children may be enhanced by adding a well designed cognitive behaviour therapy intervention which teaches the older antisocial child or young antisocial teenager perspective taking skills, social problem solving skills, anger management skills and missing social skills.

The research reviewed in this report suggests that most of the traditional interventions for antisocial adolescents have a relatively small effect on antisocial development. A number of meta-analyses of delinquency treatment programmes have found that the average effect of these programmes is to reduce offending by about 10%. This effect is very much smaller than the effect produced by interventions with younger antisocial children. Given the very large cost to society of offending (over the lifetime of the offender), however, interventions which produce a 10% reduction in offending may, nevertheless, still represent a worthwhile investment.

Many of the interventions which are currently being provided for adolescents with severe antisocial behavior difficulties have never been shown to have a positive effect on the future quality of life of such adolescents. Included under this heading are probation and parole, individual counselling, group counselling, family counselling, activity centres, alternative education programmes, interpersonal skills training, mentoring, outdoor programmes, vocational counselling, and deterrence programmes such as shock incarceration (boot camps) and "scared straight" programmes.

The three intervention programmes which appear to have the largest effect in reducing the offending of antisocial adolescents are Multisystemic Therapy, Functional Family Therapy, and Multidimensional Treatment Foster Care. The treatment programme which has been most extensively researched and which appears to have the strongest effect on social and academic development while students are in the programme is the Teaching Family programme. These are all multi-modal, community-based, skills-oriented interventions which attempt to remove the conditions which have been maintaining antisocial development. The elements which are common to these four interventions are as follows: (a) they are longer and more intensive than the interventions required for younger antisocial children, (b) they intervene in multiple contexts - the home, the school, the peer group and even in recreational settings, (c) they are highly structured rather than experiential and unstructured. (d) they are being delivered by highly trained and experienced therapists and foster parents (rather than by paraprofessionals and teacher aides as is often the case in New Zealand), (e) they recognise that effective interventions for antisocial teenagers require the therapist to build a positive relationship with the antisocial teenager and (f) they tend to be very expensive - much more expensive than interventions (of similar effectiveness) delivered to younger children and their families.

Finally, there appears to be a growing gap between what has been discovered as a result of the research reviewed for this report and what is currently being provided by way of services for children and youth with severe antisocial behaviour difficulties. This has a number of implications for the training of classroom teachers and special education personnel at each level of the educational system. The most important of these implications are explored in the final section of this report.

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