Conduct disorders in children

Abstract

Parent programmes are effective but training and provision are inadequate

In this week's BMJ, Hutchings and colleagues report a randomised controlled trial¹and a cost effectiveness analysis² of a preventive intervention in parents of preschool children at risk of developing conduct disorder. The Incredible Years basic parenting programme was offered for 12 weeks in 11 socially disadvantaged Sure Start areas. The programme significantly improved antisocial behaviour as measured by the Eyberg child behaviour inventory (difference 4.4 points, 95% confidence interval 2.0 to 6.89, effect size 0.66). The cost was between £1300 (€1900; $2500) and £2000 per child,² which is comparable to most psychological treatments and a fraction of the long term cost to society of untreated conduct disorder, which is 10 times that of controls.³ The study shows that effective community level prevention is possible using regular service staff if they are properly trained in an evidence based programme.

Conduct disorder is a major health and social problem. It is the most common psychiatric disorder in childhood, with a prevalence of around 5% across the world,^{4 5} which is rising.⁶ The diagnosis is given to children who display persistent severe antisocial behaviour such as tantrums, verbal and physical aggression, lying, stealing, and violations of other people's rights. Although the greatest damage to society is done by delinquent adolescents, the disorder usually starts below the age of 7 years with the oppositional defiant subtype.⁷

Ineffective parenting and poor disciplinary practices at home and at school are major determinants of this disorder, which has widespread effects on many levels of society. The management of this disorder requires input from the education sector, social services, and the police. The health service should be involved too, for several reasons. Firstly, there is a substantial genetic influence on the causation of conduct disorder⁸; secondly, it is often associated with neuropsychological disorders, such as attention deficit hyperactivity disorder⁶; thirdly, the disorder has physical health consequences such as increased accidents and higher suicide rates; and finally, mental health professionals have led the way in developing effective assessments and treatments.

Last year the National Institute for Health and Clinical Excellence (NICE) released a health technology assessment on the effectiveness of parent training and education programmes for the treatment of conduct disorders in children.⁹ This year, the UK government will launch a new National Academy for Parenting Practitioners.

The health technology assessment recognised the need for wider involvement and was jointly commissioned with the Social Care Institute for Excellence. Based on a meta-analysis of 37 randomised controlled trials, it concluded that parent training programmes seem to be effective. The mean effect size was close to 0.8 standard deviations on parent report measures and 0.5 standard deviations on direct observation. These effects are of the same order of magnitude as for antidepressants in adults. The assessment is misleading, however: it states that the trials were “of poor quality” only because they did not report their methods of randomisation or concealment in detail, something which has not been the tradition in psychology journals. In fact, all the trials were randomised (usually by reputable university statisticians) and most used high quality methods and measures, so their conclusions are sound. In future, NICE should contact trial authors for this missing information. The report also urges caution because most trials were from the United States, yet there have been several UK studies showing similar effectiveness.^{10 11 12}

Future research should investigate the long term effectiveness of parenting programmes; which aspects of parenting need to be changed (both a reduction in negative parenting and an increase in positive parenting seem to mediate changes in children's behaviour)¹¹; which techniques are most effective; and what modifications, including compulsory attendance orders, are needed to reach the most disorganised and abusive families.

Health commissioners and providers have far to go in delivering the quantity and quality of services needed. Currently, only a quarter of children with conduct disorder receive specialist treatment,¹³ which may not be delivered according to NICE guidelines, as fewer than 1000 practitioners are trained in programmes recommended by NICE. It is unlikely that such failure to provide most patients with effective treatment would be tolerated for a physical condition such as childhood asthma, yet the long term morbidity and quality of life are probably at least as bad in conduct disorder.

Within existing National Health Service provision, the health technology assessment may begin to shift practice, but NICE should now commission practice guidelines for assessing and treating conduct disorder. As well as parenting programmes, child anger management and problem solving treatments can be effective; the value of medication is dubious. A major problem for expanding provision of parenting programmes is that postgraduate courses in psychology and psychiatry have limited capacity for training in behaviourally based methods. Consequently, much training is carried out by producers of commercially marketed programmes, which although usually of high quality are short (typically three days) and cover only one particular approach.

Cross governmental responsibility for severe antisocial behaviour was recognised in the “respect” agenda launched by the prime minister last year. This included plans for a National Academy of Parenting Practitioners,¹⁴ which will oversee training of the parenting workforce across statutory, voluntary, and private sectors. It remains to be seen whether the academy will be able to persuade practitioners outside the health service to adopt effective practices. But if the health technology assessment and the academy lead to the dissemination of high quality, evidence based approaches they could have a major impact on children's health and wellbeing by improving the outlook for those with conduct disorder.