‘The costs of Conduct Disorder and evidence for parenting interventions’ Madeline Marczak

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Madeline Marczak on ‘The costs of Conduct Disorder and evidence for parenting interventions’

Recorded on 19 April 2018 at the North West ACAMH Branch as part of a conference on Conduct Disorder.

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Madeline Marczak – So good morning everybody, and I’m delighted to be here this morning and thanks for the introduction.

[inaudible 00:00:19] So, yes, I am a psychologist by background and I split my time between a clinical post working in a specialist [inaudible 00:00:28] in Central Manchester. We’re fortunate, I guess, in Central Manchester that we have some specialist funding to be able to think about early intervention, which I guess is my passion, so I hope that will come across this morning.

We’ve got sort of a 20 year history in terms of the children parent service, which is what the service is called, about providing evidence based parenting interventions.

We were really lucky to be sort of listed in the NICE Guidance of Conduct as a best practice site for delivering parenting interventions in line with the NICE guidance.

So that’s a sort of typical role and then the other part of my working life, I spend three days a week leading for the Northwest PI Programme in relation to parenting and also 0-5’s. For those of you, just in terms of a show of hands, is everyone familiar with what CYPI* is or do I just need to give a bit of an explanation?

OK, so for those of you who don’t know what it is, it’s a collaborative project between the Department of Health and Health Education in England. It’s about really trying to think about service transformation within CAMS and being able to think about how we can ensure that we are skilling up and training the workforce in evidence based interventions that they can deliver locally.

So today, what I’m going to spend my time thinking about is, yeah, why parenting and what we know from the evidence base, I guess, in terms of what works, in terms of parenting intervention, the conduct disorder.

So in terms of just to give you a bit of an overview, this is what I am hoping to cover on.  So to just spend a little bit of time first thinking about why do we need to intervene? Why is this such an important area for us to be thinking about and to think about the sort of cost of conduct disorder, not only in relation to the child and personal family, but also the sort of broad fiscal costs in terms of an economic intervention and then spend time thinking about so why is parenting intervention so crucial in relation to this?

I’m going to then focus on a specific parenting intervention called the Incredible Years. That’s because it’s the programme that we’ve got most experience of in Manchester. Also it was the parenting programme that was adopted by all seven of the CYPI* sites nationally and I’ll tell you a little bit about why that was at that time in terms of the evidence base. And I guess increasingly, and I’m sure all of us in this room know just how tricky sort of achieving sustainable implementation of any evidence based practise intervention is, and some useful literature that’s beginning to emerge in terms of sustainable implementation, in terms of evidence based practise.

So I thought it might be helpful to spend some time towards the end of the presentation just thinking about what do we know that makes it work in the longer term, and how do we try and achieve sustainability in our services in terms of these models.

Does that feel okay?  Is that what people were kind of hoping for?

OK, so let’s think about these costs then. So in terms of cost more broadly, I guess the most important place to start is what are the costs to the child and personal family in relation to conduct disorder?

So we know this sort of top aspect of this slide is to say conduct disorder remains the most common child adolescent mental health problem. It’s estimated about five point eight percent of the UK child population will go on to receive a diagnosis of conduct disorder.

I guess this stat feels really important for me that we’re able to think about how we respond to this not only within CAMS, but also within community CAM settings. I think in relation to conduct disorder or broad behavioural, the severity of behavioural problems, unfortunately our services remain quite fragmented in terms of the support that we’re able to offer to families. I think the very fact remains the most common mental health problem is that we do need to take some collective responsibility about how we intervene across agencies as opposed to sort of compartmentalising and fragmenting our approach to conduct disorder. I guess the reason for that is that, unfortunately, the trajectory of children who have a diagnosis of conduct disorder is unfortunately an incredibly stark one.

So fifty percent of children who get a diagnosis of conduct disorder will go on to develop antisocial personality disorder as adults. This is massive and 70 percent, there’s a 70 fold increase in being imprisoned  by the age of 25 if you have a diagnosis of conduct disorder. So your life chances are significantly affected if you have this diagnosis in childhood.

So the costs for the individual and the family system are very significant, and I guess something that just should be alarming to us in terms of the importance of us being able to ensure that we can intervene in ways that ensure an effective intervention in relation to this.

OK, so I guess our services though at the moment, they don’t just rely on effectiveness of intervention for the child or the health system, but recently we’re being asked to provide evidence in terms of how our service is cost effective. I guess in relation to conduct disorder the economic argument is increasingly as strong as that in terms of intervention for the individual.

So this is a study that was done by Scott [inaudible 00:06:32]  in 2001. So really helpful, epidemiological study that was done in Central London. So it was helpfully a UK based sample. What Scott looked at is what were the overall costs for an individual if he were aged 10 or 28 and if you had no behavioural problems or if you had a diagnosis of conduct disorder?

So what I want you to just look at is this figure here. So what they found is that the total cost annually for children without a diagnosis of conduct disorder or behavioural problems was roughly about seven and a half thousand pounds.

By the age of twenty eight, for those individuals with conduct  disorder, it was about 10 times higher. So it’s about seventy thousand pounds. So Edwards et al. he translated these prices, these sort of costings, in 2009, 2010 prices. So they’re probably going to be even a bit more inflated now and again, roughly sort of just under ten thousand pounds per child without conduct disorder or adult without conduct disorder and then about ninety two thousand pounds per 28 year olds with conduct disorder.  So the costs are significant in terms of the services that children, young people and then adults that go on to use, that have a diagnosis of conduct disorder.

What Scott found was that these costs were spread across services but the most significant cost was in relation to crime. So nearly forty five thousand pounds was attributed to crime spending, given an early diagnosis of conduct disorder. But what we also saw is that these children and young people actually used a broad range of services, tend to be more heavily used as a social care and often needed specialist educational provision. So these costs also then increased  within these sectors.

OK, so I guess this is about us thinking about costs that span across sectors which again, I guess makes this specific mental health problem one that does need a multiagency approach. So [inaudible 00:08:58]  for mental health in 2009 about 80 percent of overall crime spending was attributed to people who had a diagnosis of conduct disorder in childhood and which related to about nearly 50 billion pounds in terms of crime spending.

And finally, so just in terms of what these costs are projections, in terms of the lifespan, Fidele* and Parsonage* in 2007, looked at a cohort of young people with conduct disorder and they sort of trashed the annual cost in terms of that cohort over a lifespan. They estimated it was probably about a five point two billion cost for an annual cohort over a lifetime of children with conduct disorder. So this is a costly disorder, not only fiscally in terms of economically to society, but also significantly that children, young people, families and communities are experiencing these difficulties.

OK, so why parenting then? So why parenting in the sort of grand scheme in terms of how we ensure effective intervention?

So I guess it will come as no surprise to you that conduct disorder has a multifaceted, a range of risk factors. So if we start with child factors, actually children with conduct disorder often have poor conflict control, impulsivity and there is a high comorbidity with ADHD. Often children [inaudible 00:10:43] or poor social skills and those factors sort of directly impact on their ability to access educational environments. There are often children who display high levels of childhood aggression. They are seen as deviant by peers and actually often experience really significant sort of peer antisocial relationship difficulties and often in relation to teaching it is often seen as sort of narratives around a naughty child or a difficult child that can’t be managed within particular settings.

Contextually they are children who often have a really tricky start.  There are children who have a number of contextual risk factors to children who are more likely to be growing up in poverty, have parental time, substance abuse or mental illness within that background, and have significant life stresses from early on in childhood. There was an interesting study done by Howorth* in 2004 that suggested that for about 40 percent of children who have experienced  domestic abuse, they were in the clinical range for behavioural concerns as opposed to only about 10 percent who hadn’t.

So it shows that domestic abuse is also significant contextual factor within the sort of systemic nature of the risk factors for conduct  disorder. It’s probably no surprise, really, but it also shows the sort of significance of the importance of comprehensive assessments. When we’re thinking about assessing conduct disorder and then thinking about intervention.

Then finally, so the bit that I’ve been spending so much time talking about, we know that there are a number of parental risk factors that are more likely to be correlated with the diagnosis of conduct disorder. So within these families, often parenting is seen as harsh and ineffective. It’s often problems in terms of consistent limit setting. It’s often seems to be poor monitoring and supervision and low stimulation in terms of one to one attention or stimulation and sort of educational activities.

I guess in terms of the argument for parenting, it’s this one that actually out of them all, is probably the most effective in terms of change, but it’s also the easiest to intervene. It’s actually quite difficult at times. We would love to be able to reduce these things, but contextual risk factors, particularly if there is a suite of them, actually it’s very difficult for us to be able to intervene. And some of these intrinsic difficulties might also make intervention in relation to the child level relatively difficult. So we can intervene here. We potentially can break these cycles in terms of the trajectory, in terms of having a conduct disorder [inaudible 00:13:42].

So I guess that’s the rationale theoretically, in terms of parent training, but again, I just want to spend some time thinking about economically what’s this argument? And also from the evidence base, why does this… sort of what does the evidence base say in terms of the effectiveness of parenting intervention?

So really usefully, in recent years there’s been a number of significant UK RCT’s that have been done in relation to parents for conduct disorder. I’m going to talk about those in a moment. And increasingly, the research trends that they, in large scale studies, also need to provide a cost benefit analysis so we can determine not only is this intervention effective in terms of clinical outcome, but also that it provides cost savings in the longer term society.

So I just wanted to share some stats in relation to that. So on this box  was the study done by the Centre for Mental Health and they looked at emerging conduct disorders in children who had a diagnosis or severity in terms of behavioural problems, perhaps pre a conductive disorder diagnosis being given. They found in relation to those children, the estimated lifelong costs were obviously lower than if the diagnosis had been given at about two hundred and sixty thousand pounds per child and actually the cost of intervention significantly  less than that.

The cost benefit of those programmes was significant, costing about one thousand three hundred pounds on average per child in terms of the parent who was accessing the parenting intervention. So I guess  significant cost savings over a lifetime in terms of that. And as the RCT’s have become more sophisticated in terms of looking at cost benefit analysis, we’ve been able to see even more sort of sophisticated analysis of cost benefit savings in relation to interventions.

So Edwards et al. in 2006, they looked at the cost benefit analysis of the large scale Wales RCT that was done, which I am going to talk about in a moment. What basically this sort of complicated graph is showing is that if a society were prepared to pay roughly up to two thousand five hundred pounds per child for a parenting intervention, we’ve got about an eight to 10 percent probability that we’ll get savings back in terms of that spending. So, again, we’re not only increasingly being able to have sort of RCT’s that are supporting the importance of intervening, but also that there’s long term cost savings in relation to that.

OK, so.

I’m sure many of you are aware of the NICE guidance in relation to conduct disorder. They are all dated in 2013 and they are really clear, actually, in terms of what we should be offering. Alongside the 2013 NICE guidance was a large meta analysis done in terms of the evidence base to try and support NICE to be able to make some clear recommendations in terms of what was effective.

Like I say, they do give really clear guidance in terms of what we should be providing and that is generally group based parent training programmes for parents of children and young people between the ages of three and 11, and that is for those children who are identified as high risk for conduct disorder or oppositional defiance disorder. They have a diagnosis of ODD or conduct disorder or that any person who has been in contact with the juvenile justice system in terms of antisocial behaviour.

They are very clear that actually the evidence base is in relation to group based parent training as opposed to individual based parent training. And there’s some exceptions in the NICE guidance for that success. Where possible, it should be indicated, you know, where severe parental anxiety might prevent parents from accessing programmes then a one to one intervention should be offered.

But as the norm standard intervention should be group based parenting interventions because the evidence base is so much greater when offered in that format.  Again, usefully it tells us what those programmes should look like. There’s been lots of research done in terms of the components of those programmes that make them effective. So generally, they should typically have between 10 and 12 parents in the group.  Groups of less than that tend to not have the same level of process or peer support or effectiveness and any more than 12 parents, often that process becomes more difficult to manage in terms of being able to tailor the programme to individual families needs.

The parenting programmes that are effective tend to be based on a social learning model. They need to include modelling, so video modelling or facilitated based modelling, rehearsals and the ability to  practice and support parents to be able to practice skills before they go back to their home environments, to try them out. Also to be given the opportunity to then provide feedback on how going away and trying some of these things have worked.

So all of these components feel really significant and ensuring that the   programme of choice has these elements. Typically they consist of 10 to 16 meetings of about 90 to 120 minutes duration. I guess this one is increasingly an important one. They need to adhere to the developers manual or basically they need to have model fidelity. So we need to be ensuring that a service is supporting all practitioners to be able to deliver interventions in the way that the evidence suggests is effective.

So just another side to this, I guess one of the things that I guess I’m asked probably at least once a month is, well, that’s all well and good but it’s really tricky to deliver group based parenting in CAMS. It would just be much more easy to do it as a one to one because that fits all our service structure and we’re really feeling pressured right now. I [inaudible 00:20:25] slightly less sessions because actually it doesn’t fit into the school half term and it just means it’s a bit tricky in terms of being able to get parents to complete this intervention.

I guess in response to those, I absolutely appreciate the very real time pressures in terms of CAMS environments currently, but just as an aside, to illustrate this point, I thought it might be helpful for us to briefly look at the NICE guidance for type one diabetes for children.

So I just want you to bear with me for this bit. OK, so I’m not a medic by background, so I’ll very briefly put these points, but roughly from my reading of the NICE guidance for kids with type one diabetes, there are four main elements that are important.

The first one is to provide education and information. The second one is to provide insulin therapy, very specific recommendations in relation to that. So they need to be either injections of [inaudible 00:21:26] insulin with every meal together with one or more separate injections of intermittent [inaudible 00:21:33] insulin, or that the child would be on insulin pump therapy. There needs to be the provision of dietary and exercise management that should be given to the whole family and not just the child and it should be blood glucose monitoring for a minimum of five times a day.

So I want us to just hold in mind if we ask service providers or commissioners in relation to diabetes, what our thoughts would be if we said, OK, so the recommendation is that we provide injections every meal. But, you know, could we just do that for one meal a day? And rather than providing blood glucose monitoring five times a day, could we just do it like once a week because it’s quite costly and it’s quite invasive in terms of this child’s and parents quality of life. Also actually, it’s pretty tricky to do exercise and diet management with a family system, so could we not just do it with the child?

I think every single one of us in this room would go absolutely no way because it means that the treatment won’t be effective. And I guess that’s a really important question that we need to think about when looking and determining the NICE guidance. That any child and adolescent mental health difficulty or disorder is that not only just in relation to conduct disorder, but the minute we start tweaking any elements of what the NICE guidance is saying, in order to try and ensure that we can make it fit within our sometimes quite stretched services, actually we increasingly loose the effectiveness of that intervention.

So the decisions that we need to make in terms of delivery of evidence based interventions is really important because often a small amount of investment at that stage will ensure effectiveness in the long term, which is what we’re trying to achieve, particularly given that poor trajectory in terms of conduct disorder.

OK, I’ve just included this slide just for information. Again, I am sure that you know, but in terms of the pre-school children particularly, and then school age children with moderate ADHD, group based parenting interventions are also the recommended treatment of choice.

That’s important for us to consider because there is this high comorbidity in terms of ADHD and conduct disorder, but it is actually the same intervention that is often indicated for both of these difficulties.

OK, so I could spend the rest of my time thinking about the Incredible Years specifically. Hopefully that provides a bit of a overview of the rules rationale for parenting, but like I said, the model that I guess, in the north west have this experience with, is in relation to the Incredible Years. This is absolutely not the only model that reveals the requirements in terms of effective parenting interventions and to just summarise what they are.

So again, this meta analysis that was linked to the NICE guidance in terms of what makes programmes effective suggested that they needed to have these components. So new parenting skills or behaviour management strategies needed to be able to be modelled and rehearsed. So that basically means role practice which again, for practitioners is a really tricky thing to do. And and I often, again, will hear from services or from clinicians saying, yes, we absolutely do the Incredible Years but parents don’t like role play and I don’t like facilitating role play, so we just don’t do that component of it.

So it’s really important that we think about training and support for practitioners to be able to ensure that they deliver programmes with the elements that we need to make them effective for parents. They need to have a component in which the majority of intervention is happening outside of the session. So for all clinically effective parenting programmes is generally home tasks that are set, parents go away and be able to do those strategies at home with that child in their unique home situations. And then importantly, they then come back to the group and provide feedback in relation to how that’s been going, or are able to be supported, to be able to implement those strategies in a way that is helpful to that.

All of these programmes that were effective, actually there was a really key aspect that this wasn’t about practitioners standing at the front and telling the parents what to do. It was ensuring that practitioners were able to fully collaborate with parents. That for parents accessing any sort of parenting intervention, the likelihood is that coming into that room, feeling unsure, overwhelmed, blamed or criticised. So these groups need to be as partners with parents, empowering them to be able to make decisions about their own parenting and what they do in terms of supporting that child as opposed to being told what is the best for that child. And again, that’s really important that we support clinicians to be able to develop appropriate skills and collaboration, and that it’s not just the content of these programmes that really pulls in, but equitably the process of ensuring that parents are sort of equal collaborative partners.

All effective programmes have non-violent sanctions for negative behaviour. So in relation to the Incredible Years that in relation to effective limit setting, time out and consequences…

I’m really sorry. I’ve got as frog in my throat…

OK, this element is really important because what we see in terms of the characteristics of children with conduct disorder is that increasingly there are coercive cycles that often occur in families.

So as a child’s behaviour becomes increasingly aggressive, violent or non-compliant, parents feel forced into providing increasingly aggressive or punitive ways to respond to that. And that leads to dangerous situations because aggression and abusive parenting that tends to increase. So we need to be able to ensure that we can give parents an alternative.

My experience with working with parents, generally, they don’t want to be smacking their children or engaging in punitive discipline, but they talk about feeling like they have no alternative, that they feel completely out of control in terms of what to do. So ensuring that they not only have support and intervention to ensure that they can increase positive attention and their attachment and their relationship with their child, but also to be supportive, to ensure they’re able to follow through with consistent and effective but yet safe limit setting is an important aspect of all of those programmes.

And most of these programmes also address difficulties in adult relationships or family relationships. And again, that feels quite significant if we go back to thinking that probably about 40 percent of these families, in Manchester it’s way higher, percentage of families who are accessing a group without a history of current domestic abuse is incredibly high, about 70 or 80 percent that actually we need to ensure that we are supporting parents to think about how to safely manage some of the contextual problems that they might be experiencing.

So in relation to these components, the Incredible Years fulfils all of these criteria, but other programmes do to. So Triple P, the Oregon Parenting Programme and Strengthening Families and Strengthening Communities all have these elements. So I’m going to talk about Incredible Years today, but I’m not saying that’s the only intervention choice. But I am going to present some research, which is why that was chosen as the intervention of choice [inaudible 00:30:09] across the country.

So, like I said, really, really helpfully, so for a long time, we’ve been trying to extrapolate sort of generally US data and applying it to our U.K. populations, which never feels ideal really in terms of making decisions about what the best interventions and service decisions for the communities that we’re working in. Since the sort of 2010 onwards there has been increasing activity in terms of UK based RCT’s, which have been done to a very high quality, that have given us some very interesting, excellent data in terms of making some of these decisions.

So one of these was commissioned by Birmingham City Council. So what they wanted to do as part of their Brighter Future initiative was to determine how they were going to spend and invest in a particular early intervention parenting strategy, but they were saying they don’t know which ones to use. We want to ensure that we are using this money in a cost effective way. So they commissioned an RCT to compare three different parenting interventions and they were the Incredible Years, Triple P and PATHS, which is a school based intervention, as opposed to a home based intervention.  Those RCT’s,  children were selected who were at high risk of conduct disorders, so three and four year olds, and they were randomised to those different treatment interventions and then comparison accordingly.

What they found is that Incredible Years yielded reductions in negative parenting behaviour amongst parents, reductions in child behavioural problems and improvements in child relationships. And importantly, those improvements were sustained over time and again, I am going to show you some data in a minute in relation to the importance of this in considering follow up in terms of these studies.

In the PATH’s trials, the intervention that was delivered through schools, there were modest improvements in emotional health and behavioural development. But unfortunately, and that was a one year follow up, but unfortunately, those effects have disappeared by year two. So, again, really important in terms of our design of RCT’s, of where possible, trying to ensure that we include a follow up to see actually are these interventions effective over time.

And unfortunately for Triple P within this study, there was no effect. There’s no significant effect at post or follow up. So there was this sort of significant question mark in relation to how this fits in with this population.

So based on this study and the cost effectiveness study that happened alongside it, Birmingham decided that they were going to commission Incredible Years for all high risk three and four year olds across the city. So there was a systematic rollout and training in terms of their staff in order to try and ensure that they were intervening early in terms of prevention of conduct disorder within the city.

So just linked to that, there has been two other U.K. RCT’s which have provided us with similar evidence. The first one was the Welsh trial. It was led by Bangor University and there was quite a dominant researcher called Judy Hutchins and they looked again at high risk children for developing conduct disorders in three and four year olds, and they delivered this large scale RCT across Wales.

Then sort of in a separate but similar related RCT, I then decided that they want to do a national evaluation of the Incredible Years, and they looked to children of a slightly older five to eight year olds. They were specifically interested in looking at children from disadvantaged areas. Again, when you think about the correlation in terms of socio economic disadvantage and poverty and conduct disorder it felt like a really important population to be thinking about.

So just to share the sort of combined results in relation to those. So,  they looked at child behaviour. So what was the impact of the Incredible Years in relation to child behaviour?

So this black line here is the clinical cut off for behavioural disorder, or behavioural concerns, as shown by the [inaudible 00:34:43]. So basically if you don’t know the [inaudible 00:34:46], its just a routine outcome measure that’s generally quite sensitive in terms of behavioural difficulties, because it looks at not just the frequency, but also management. So it’s often used as a more sensitive measure to the SPQ.

And they found sort of not surprisingly, that the mean score for children was that they were in the clinical range on the [inaudible 00:35:13] for behavioural problems and pre-intervention.  Post  intervention this is a really interesting finding. So both the Wales and Ireland study post intervention, these children are falling from clinical to non-clinical ranges. So there was an absolute sort of clinical significance in terms of taking children out of the risk factor for behavioural problems and most importantly, these changes were then sustained over time.  So at 12 and 18 months, it was still in non clinical ranges on the [inaudible 00:35:45].

In terms of parental depression, that was also looked at because this high correlation between conduct disorder in children and parental depression in adults, and that’s probably a two way process. We know that the risk factors for conduct disorder include parental mental health difficulties, but also managing a child conduct disorder is likely to be incredibly stressful. So actually increased prevalence in terms of depression is very frequent when intervening in terms of these families.

Again, this black line is an indication of clinical cut-off. The mild depression as shown by the BGI’s with depression inventory and again pre intervention for both groups, the mean, are within the clinical range. So the parents were generally scoring in the clinical range for depression pre-intervention.

Post intervention, at six months again, parents have gone into nonclinical range, so actually a child’s behavioural parenting intervention and actually showed significant improvements in parental mental health, which again shows that significance in terms of multiagency thinking.

This is a multi agency benefits in terms of our successful intervention strategy. Again, that this was shown to be sustained at 12 months and 18 months follow up. So parental mental health was also then sustained over time.

I guess, like you say, in terms of increasingly… there’s a lot of literature around implementation science, which is basically about how do we do that? So it’s incredibly difficult to implement evidence based intervention in a sustainable way.  I know that in relation to my experience in relation to CYPI*, it’s the whole systemic approach in terms of thinking about how we embed evidence based practise organisationally within particular settings. That’s by no means easy. There’s all sorts of organisational barriers that make that incredibly challenging and this sort of increased area of research which is looking at this implementation science sort of can help us to provide some answers in terms of what we should be thinking about when developing services in relation to parenting, conduct disorder, and that we don’t just do things in an ad hoc way, but we think about how we would want to pilot those, ensure effectiveness and then hopefully try to achieve sustainability over time.

So what does this literature say who it works for? So it says that social disadvantage did not predict poorer outcome, the Incredible Years or for parenting intervention more broadly. And that’s a really significant finding because like what we talked about, conduct disorder, it’s got much higher prevalence in social and economic disadvantage. So it was really important to see that actually those changes were still seen across the communities in which we are working in.

It was shown that for boys, particularly, and younger children and their parents who tended to have higher levels of depression, the programme was more effective. So, again, it shouldn’t be there for that parental mental health, as an indicator is something that we say that this doesn’t warrant intervention or that it warrants individual intervention. Actually, the very fact of parental mental health being involved, or in the mix, in terms of some of those contextual risk factors was actually a positive indicator of successful outcome.

Whereas in contrast, interventions for serious antisocial behaviour in adolescents tend to be much less effective. So the sort of evidence is  that the earlier year we are able to intervene in relation to conduct disorder, the likelihood of the better outcome in the longer term. So it’s not rocket science, but the research backs up our thinking in relation to that.

So just linked to that, this is a slide from the Incredible Years. But it’s an interesting one because if we look at this top black line, these are children with high levels of aggression. So actually, the children who are aggresive toddlers who are then likely to become aggressive adolescents or adults, it shows that this trajectory remains quite fixed over time.

So actually, our ability be able to intervene in relation to conduct problems has definitely got the window of effectiveness. If we don’t intervene at that time, it tends to then be a fixed pattern that is sustained throughout sort of older adulthood, adolescence and then in later life. Again, that’s not rocket science. We know from the beginning of this presentation about some of the unfortunate trajectory statistics in relation to criminal behaviour, in relation to the correlation between conduct disorder in childhood and later criminal activity. So it’s no surprise that it suggests that we need to be intervening early and providing early intervention of under fives in order for us to ensure prevention as well as treatment of conduct disorder.

I just thought I would include this slide because it’s one of my favourites working with early intervention, and it just makes me as passionate about this area as I am. It’s just a nice illustration of this, really, in terms of our spending of some of these difficulties over time.

So we know this pink line is our brains capacity to change. So we know by the age of three the brain is developed to about 90 percent of its adult capacity and the majority of that brain development [inaudible 00:41:44]. So as the brain becomes increasingly myelinated and so neural network pruning has happened, it then becomes less likely and more rigid to change. That’s why I guess we should definitely learn  foreign languages in early childhood, because it is increasingly difficult to do that in older childhood and later childhood.

But this graph is slightly flawed, there probably should be a peak here in terms of adolescence where the brain goes through a lovely sort of reorganisation and also is this lovely opportunity in terms of therapeutic change at that time.

Well, actually, it’s still quite frank and stark that actually brain development and flexibility of intervention for change is much more likely before the age of three. And if we contrast this to the black line, this is public spending in relation to intervention, and what we see is that actually our nought to five services, so the services that potentially ensure the biggest capacity for change, have the lowest public spending. As we go on into adolescence and then older adulthood, actually our spending significantly increases. But actually at a time where change may be just much more difficult in relation to thinking about capacity to change. I’m absolutely not saying that it’s all hopeless and we can’t change or intervene in late adolescence or adulthood. I guess what I’m saying is that we need to think again about a lifespan and perspective in terms of thinking about conduct disorder, that we’re not only thinking about treatment and intervention when problems are really significant for society or in more services, which potentially might be adolescence or adulthood. But we’re also able to take a preventative approach in terms of early childhood.

The other thing about implementation science is that it’s told us a little bit about effectiveness of intervention depending on facilitated training and skill.  What Scott et al in 2008 found was that therapy skill  had a major influence on parent training group outcome and that was even when a whole load of other variables were controlled for. So things like hyperactivity, child age, aspects of the therapeutic process or therapeutic relationship and the ability to sort of control those factors is important because it suggests that we really need to ensure that we invest in appropriate training and on ongoing model specific supervision to ensure that we can provide facilitators with appropriate training to be able to deliver interventions that are in line with how it’s done in the research, which suggests how we get effective interventions.

Again, I think that’s an interesting thing for us to think about because increasingly it seems like parenting is being moved out of CAMS and is increasingly moving into voluntary or independent sector organisations, which is a helpful and this is definitely a community CAMS problem.

We need to be able to think about families accessing support in accessible ways. What we therefore need to ensure is that whoever is providing these interventions has been supported appropriately to be able to deliver them in line with model fidelity.

OK, so what are the key lessons learnt from this implementation literature?

So it’s that we should know what outcomes and change is required. Do we want to lead to significant clinical reductions in behaviour problems? Do we want to improve mental health? Do we want to reduce antisocial behaviour?

We then need to select some evidence based programme that’s suited to that target population and that probably fulfils those criteria [inaudible 00:45:47].

We need to be able to have a strategy in terms of how we identify those children that are at high risk of developing conduct disorder and address sort of relevant service access issues. So in Manchester we deliver all our programmes within children’s centres just because it ensures that parents are able to deliver intervention at a location that is convenient and local to them, and that often they’re able to sort of have some familiarity with.

We need to ensure staff training and ongoing support and like I said, that needs to be through specialist training and ongoing model specific supervision. And I guess we need to factor that into how we ensure the ongoing nature of that within service transformation. We need to ensure implementation fidelity.

This is just… I’m not going to go through this, but the Incredible Years provides a bit of guidance in terms of service developers or commissioners, in terms of what things they might need to consider in terms of thinking about sustainable implementation over time.

And it’s interesting because most groups fail actually at this logistic level. They don’t have the correct materials. They can’t access a room. You can’t be able to sort of access funding to have a fresh facility and therefore it just fails. And actually investment here, again a small amount, often does lead to successful implementation of programmes in addition to this next level, which is the type of practitioners that we’re training. So selection of practitioners who want to do this work and who are skilled at it and the appropriate training and support so they can do it with model fidelity.

I’m not going to go through this, but in relation to CYPI*, I have to guess that’s the reason why we are doing what we are at the moment. The CYPI* in relation to parent training means that professionals from both CAMS, voluntary, social care and independent services can access high quality training and most significantly, really intensive model specific supervision over that year period. So actually that their sort of skill and competency development is sort of exponential over that year in terms of them being able to provide effective intervention.

So I guess my closing message in relation to conduct disorder is that we probably have to speculate to accumulate. We need to be able to think about intervention as well as reactive management of conduct disorder.  So prevention as well as intervention in later life. And I guess, given the broad ranging and systemic outcomes in terms of the disorder, we do ever increasingly need to be thinking about some multi agency approach to intervention in terms of conduct disorder, in terms of health, education and crime as opposed to some of that feeling like it just sits within health.

OK, thank you.

Speaker 2 – Three questions.

Speaker 3 –  I think you made a very good point with that video and I was really struck by the fact how that mother was really motivated, it was really appreciated the improvement in school attendance and your final sentence almost [inaudible 00:49:28] as if you think about. So, yes, we have evidence that we [inaudible 00:49:32]  However, where should we do it? How should we do it? If it was a partnership with somebody like education or social care [inaudible 00:49:46] and that motivation can actually be able to [inaudible 00:49:50].

Madeline Marczak – I completely agree. So in Manchester, CAMS works as a multi agency organisation. So it’s clinical psychologist who sit within health. We do provide… we still deliver interventions, but our main role is to model specific situations, support and sustainable implementation of programmes over. Then our parent communities who deliver those programmes sit within the local authority, Barnardo’s, Action for Children and [inaudible 00:50:21], so charitable and independent organisations. We deliver them in community settings at children’s centres, but our links with schools are significant and in relation to  [inaudible 00:50:35] pilot partners as well, we’ve got increasingly school staff who train in [inaudible 00:50:41] so they can deliver in school base settings.

So I agree. I don’t think there is a perfect fit for all, but the more they could be community based, multiagency sort of programmes, the better and I guess that might be the delivery that say sits with education but CAMS remains a partner in terms of support for model fidelity or supervision.

So I think increasingly us being creative about our arrangements [inaudible 00:51:10] that feels significant.

In relation to that because of the GM transformation, Andy Burnham has made one of his key indicators of school readiness at the moment. So he’s really interested in terms of thinking about parenting intervention early on in relation to school readiness. So actually, I think we’ll increasingly see more of a shift across Greater Manchester in relation to intervention occurring between schools, I think.

Speaker 4 – Very, very good.  Number one, in the outcomes that you are looking at, the one that I was looking at was educational items, particularly [inaudible 00:51:51].  The second one [inaudible 00:51:53]. So my next question is, what is the next thing that you’re going to do in terms of embedding it within the community in a multi disciplinary setting [inaudible 00:52:32] and the final one is what about as research changes you [inaudible 00:52:45].

Madeline Marczak – Yeah, I agree with all the points.

I think the decimation of Sure Start has been a significant thing for us as a service because we are a nought to five service. I think it is, you’re absolutely right. I think I agree that there’s something about how do we dynamically evolve and adapt to ensure that we fit with our current community settings but also that we remain on top of the research and adopt intervention accordingly. This is a really interesting new parenting interventions that it’s something called EPECK* study that’s been done by the Parent Child Centre in London.

And they’ve got a number of pilot sites, one of which is in Blackpool, in the Northwest, and that programme has different components to the ones that previously have been found to be effective. So they are  much more parent lead and parental empowerment and they are sort of emerging CT’s in terms about literature is increasingly promising.

So I think we do absolutely need to ensure that we keep track of developments to ensure that, yeah, we don’t just deliver out the same stuff. And I guess linked to that is that you don’t just look at the broad evidence base, but we really ensure we are able to capture locally our outcomes. In Manchester we continue to use the BDI*, Bergen* and PSI* for all our parents pre and post intervention.

And at the moment we find similar outcomes in terms of the RCT’s. So clinical to non-clinical. The minute that starts to change, we need to do something about it. But if we want to do that, we need effective routine monitoring to help make sensible decisions. But yeah, thank you for your points. I think they are all really relative.

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