Kathryn Bennett

Conduct Disorder: Long-Term Outcomes and Intervention Effectiveness

OBJECTIVE To review the literature on conduct disorder in two areas: long-term outcome and the effects of interventions. METHOD The sources of the articles for review were computer searches, but the articles were selected for this review to illustrate key findings in the long-term outcome area and to review critically four intervention strategies to prevent or treat conduct disorder, namely, parent- and family-targeted programs, social-cognitive programs, peer and school-based programs, and community programs. RESULTS Conduct problems in childhood predict the same increased rates of psychiatric disorder overall in men and women but the patterns are different: for externalizing disorders, the prediction is stronger in men and for internalizing disorders, the prediction is stronger in women. In the intervention domain, the literature provides limited evidence of the effectiveness of either primary or secondary prevention. CONCLUSIONS Prospective studies of community samples of children provide the best opportunity to understand more thoroughly the adult outcomes of conduct disorder. Because of the heavy burden of suffering of conduct disorder, and the limited effectiveness of clinical interventions, there is a compelling argument in favor of an increased emphasis on primary prevention efforts.

The measurement iterative loop: A framework for the critical appraisal of need, benefits and costs of health interventions

A framework for organizing health services data is presented that subdivides the spectrum of health information into subgroups that constitute a logical progression from quantifying the burden of illness, through identifying its likely causes, to validating interventions that prevent or ameliorate it and evaluating their efficiency, to monitoring the application of these interventions and coming full-circle to determine whether the burden of illness has been reduced.

Guidelines for the clinical and economic evaluation of health care technologies

The health care system is routinely confronted with promising new technologies. In the past, most new technologies have been integrated into clinical practice without a rigorous demonstration of their effectiveness or efficiency. In order to provide a more rational approach to the adoption and utilization of health technology a comprehensive set of guidelines for both clinical and economic evaluation is proposed. While conceived of as an ideal that is unlikely to be universally met in practice, it is argued that decision making can be improved by striving towards this goal. The clinical guidelines stress the advantages of subjecting major new technologies to randomized controlled trials and insisting upon a demonstration of patient benefit in the application of diagnostic technologies. The economic guidelines stress comparisons with relevant alternative uses of the resources and the assessment of the impact on the quality of life. While application of the guidelines will produce rigorous and useful evidence, the final decisions concerning the allocation of health care resources must rest fundamentally on social value judgements and not solely, or even primarily, on informed expert opinion.

Methotrexate in rheumatoid arthritis. Indications, contraindications, efficacy, and safety.

Evidence on the safety and efficacy of methotrexate as a second- or third-line agent for treating patients with rheumatoid arthritis is reviewed. Four placebo-controlled clinical trials have documented short-term benefit from methotrexate; although true remission is rare, patients receiving methotrexate showed a 26% (95% confidence interval [CI], 17% to 35%) greater improvement in their inflamed joint count and a 39% (95% CI, 26% to 51.5%) greater improvement in pain than did controls receiving nonsteroidal anti-inflammatory agents with or without prednisone. With respect to long-term benefit, improvement usually occurs within 1 month, reaching a maximum at 6 and then leveling off for the duration of treatment; in some patients, the benefit may wane after an initial satisfactory response in the first 4 to 6 months. In one third of those given methotrexate, treatment had to be discontinued because of adverse effects, less than 1% of which were life threatening. Careful baseline and follow-up monitoring is recommended until more data on the safety of methotrexate are available.

Does low reading achievement at school entry cause conduct problems

Conduct problems place children at increased risk for a broad array of negative health and social outcomes that include conduct disorder, injuries and violence, school failure, substance abuse, depression, and suicide. Prevention interventions have the potential to interrupt the chain of events linking early conduct problem symptoms to future negative life outcomes, but have received much less emphasis than interventions designed to treat established cases of disorder. Reading problems are a well-established correlate of conduct disorder. However, whether or not reading problems cause conduct disorder continues to be debated. If they are in fact a causal risk factor this would justify the design and evaluation of interventions designed to enhance reading skills and/or remediate problems. In this paper we use logistic regression techniques to evaluate the relation between reading achievement at school entry and conduct problems 30 months later, in a representative, non-clinic sample of kindergarten and grade one children, in Ontario, Canada. The findings show that an eight point increase in reading scores (equivalent to an moderate effect size of 0.5) would result in a 23 per cent decrease in the risk of conduct problems 30 months later, after controlling for gender, income and baseline conduct problem symptoms. We conclude that reading problems may contribute to the early onset of conduct disorder. Randomized experimental studies designed to evaluate the effects of reading programmes in non-clinic samples of children are needed to: (i) establish whether the link between reading problems at school entry and conduct disorder is causal; and (ii) determine whether reading intervention programmes are an effective conduct disorder prevention strategy.

Annotation: Do Measures of Externalising Behaviour in Normal Populations Predict Later Outcome?: Implications for Targeted Interventions to Prevent Conduct Disorder

Mental health professionals involved with the care of children and adolescents are frequently confronted with questions about the risk of later troublesome outcomes. Of particular concern is whether the presence of certain risk factors warrants the provision of an intervention. The presence of externalising behaviour symptoms is regarded by many as the single best predictor of risk for future conduct disorder and antisocial behaviour (Loeber, 1991; Lynam, 1996; Moffitt, 1993; Patterson, 1993; Yoshikawa, 1994). These symptoms include aggression against others, destruction of the personal property of others, temper tantrums, and noncompliance, to name but a few. The evidence suggests that when these behaviours are present in childhood there is an increased risk for persistent, life-long psychosocial problems (Loeber, 1982; Loeber & Dishion, 1983; Moffitt, 1993; Olweus, 1979; Yoshikawa, 1994). For example, a link between the early onset of externalising behaviours and the later development of conduct disorder, antisocial behaviour, and substance abuse has been documented in both longitudinal and retrospective studies (Caspi, Moffitt, Newman, & Silva, 1996; Farrington, 1990; Robins, 1978; Tremblay, Pihl, Vitaro, & Dobkin, 1994; White, Moffitt, Earls, Robins, & Silva, 1990; Zoccolillo, Tremblay, & Vitaro, 1996). The risks associated with externalising symptoms and the relatively modest effectiveness of treatment for established cases of conduct disorder and antisocial behaviour (Kazdin, 1997; Offord, 1989; Offord & Bennett, 1994) have led to an increased emphasis on the provision of preventive interventions (Institute of Medicine, 1994; Reiss & Price, 1996). It has been argued that intervention should be provided to high-risk children as early as possible. Claims have been made that even in nonclinic populations of children as young as 4 and 5 years of age, 50% or more of those with troublesome externalising symptoms will develop persistent psychosocial problems (Campbell, 1995; Coie, 1996; Reid, 1993; Reid & Patterson, 1991).

Predicting conduct problems : Can high-risk children be identified in kindergarten and Grade 1?

Externalizing behavior symptoms (EBS) in childhood are a strong predictor of future conduct problems. This study evaluated their predictive accuracy using logistic regression and receiver operating characteristic curve techniques. EBS, alone and in combination with other child and familial risk factors, were used to predict conduct problems 30 months later in a nonclinic population of kindergartners and Grade 1 children. The sensitivity (Sn) and positive predictive value (PPV) of EBS alone were below preset criteria of > or = 50% for each (prevalence < or = 15%). Sn and PPV increased when other child and familial factors were combined with symptoms but did not exceed the preset criteria. From a developmental perspective, substantial stability of EBS exists over time. However, from the perspective of prevention science, significant levels of misclassification will occur when EBS are used to designate high-risk status under the low-prevalence conditions of normal populations.

A randomized clinical trial of the Leboyer approach to childbirth.

To examine the effects of the Leboyer method of delivery, we randomly assigned 56 women to either a Leboyer or a conventional delivery and used a variety of clinical and behavioral measures to assess the outcome in mother and child. No differences were noted in maternal or newborn morbidity, in infant behavior in the first hour of life, at 24 or 72 hours post partum, or at eight months of age; or in maternal perceptions of her infant and the experience of giving birth, except that eight months after delivery, mothers who had used the Leboyer method were more likely to say that the event had influenced their childs behavior (P = 0.05). Women who expected a Leboyer delivery had shorter active labors (P = 0.03), suggesting that psychologic factors (expectations) influence physical outcomes in perinatal medicine. Our results suggest that the Leboyer procedure has no advantage over a gentle, conventional delivery in influencing infant and maternal outcomes.

Types of parental involvement in CBT with anxious youth: A preliminary meta-analysis

OBJECTIVE Meta-analytic studies have not confirmed that involving parents in cognitive behavior therapy (CBT) for anxious children is therapeutically beneficial. There is also great heterogeneity in the type of parental involvement included. We investigated parental involvement focused on contingency management (CM) and transfer of control (TC) as a potential outcome moderator using a meta-analysis with individual patient data. METHOD Investigators of randomized controlled trials (RCTs) of CBT for anxious children, identified systematically, were invited to submit their data. Conditions in each RCT were coded based on type of parental involvement in CBT (i.e., low involvement, active involvement without emphasis on CM or TC, active involvement with emphasis on CM or TC). Treatment outcomes were compared using a 1-stage meta-analysis. RESULTS All cases involved in active treatment (894 of 1,618) were included for subgroup analyses. Across all CBT groups, means of clinical severity, anxiety, and internalizing symptoms significantly decreased posttreatment and were comparable across groups. The group without emphasis on CM or TC showed a higher proportion with posttreatment anxiety diagnoses than the low-involvement group. Between posttreatment and 1-year follow-up, the proportion with anxiety diagnoses significantly decreased in CBT with active parental involvement with emphasis on CM or TC, whereas treatment gains were merely maintained in the other 2 groups. CONCLUSIONS CBT for anxious children is an effective treatment with or without active parental involvement. However, CBT with active parental involvement emphasizing CM or TC may support long-term maintenance of treatment gains. RESULTS should be replicated as additional RCTs are published.

Cognitive Behavioral Therapy Age Effects in Child and Adolescent Anxiety: An Individual Patient Data Metaanalysis

Investigations of age effects on youth anxiety outcomes in randomized trials (RCTs) of cognitive behavior therapy (CBT) have failed to yield a clear result due to inadequate statistical power and methodologic weaknesses. We conducted an individual patient data metaanalysis to address this gap.