Sainsbury urges "try something long-term today"

The UK Sainsbury Centre for Mental Health [1] is the latest UK policy lobbyist to use cost benefit evidence in the effort to persuade government to invest in prevention and early interventions strategies.

Calculations doing the rounds following publication of The Chance of a Lifetime: Preventing early conduct problems and reducing crime [2] indicate that children with conduct problems go on to commit four-fifths of all crime in later life and that much of it might be prevented by universal preschool provision.

The other side of the increasingly familiar argument is that action to prevent conduct problems in young children can dramatically reduce their chances of offending later in life, with enormous cost advantage to themselves, the care and youth justice systems and society.

The crux of the case put by the London Centre’s joint CEOs Sean Duggan and Bob Groves is that for just 1% of the annual law and order budget it would be possible to fund a comprehensive program of preschool support for 30% of all children born in the UK each year.

Duggan said: "The cost of crime related to conduct problems is some £60bn ($100bn) a year. Yet conduct problems can be prevented by effective action. Preschool parenting support for families at risk is especially good value for money. One US scheme has been shown to reduce the costs of crime by $11 for every $1 invested in it.

The US scheme in question, described in some detail in the report, is High/Scope Perry Preschool program, developed in Michigan in the 1960s and notable for the length of follow-up study it has permitted.

"Cumulative benefits measured in absolute terms were estimated at nearly $260,000 per participant, and just over two-thirds of this total was accounted for by savings in crime-related costs, ie. around $175,000 per participant.”

The report maintains that most of the remaining benefit accrued in the form of higher earnings for the participants. “But, even if the program is assessed purely as a crime prevention measure, it has still yielded a return of more than $11 for every dollar invested. By any standards, this is an extraordinarily high return for public spending."

Duggan and Groves also rely on activity at the Washington State Institute for Policy and Practice led by Steve Aos, which has sought to assess cost effectiveness across a range of crime reduction and other early intervention programs. [For coverage of Steve Aos’s work, see for example, Can eleventh hour prevention stitch be in time? [3]]

“These reviews confirm that, although there is a good deal of variation in cost effectiveness between programs, there are a number of well-designed therapeutic interventions, applying to children and adolescents, which represent extremely good value for money for taxpayers.”

The authors acknowledge another Washington finding: that for adolescent offenders, therapeutic programs are more cost effective than interventions such as boot camps or intensive parole – indeed that by most calculations, punitive measures have negative returns.

The sweep of the generalization that children with conduct problems are responsible for 80% of all crime is moderated by findings published in 2005 by David Fergusson who identified a “prevention paradox”: that those belonging to a high-risk group are at increased risk of an adverse outcome, but the majority of those experiencing the outcome do not belong to the high-risk group”.

Duggan and Groves comment: "This is indeed the case in relation to offending outcomes. The evidence shows that while individuals with a clinical diagnosis of conduct disorder are particularly likely to become offenders, they nevertheless account for a smaller proportion of total crime than the much larger number with sub-threshold conduct problems.”

One reckoning was that preventive efforts should apply across the full range of a risk factors rather than being concentrated at the clinically significant extremes.

That public health, "mean-versus-tail" argument is supported by more recent work by Fergusson and his team at the University of Otago, where they have been examining the slipperiness of "conduct disorder," suggesting that it may be context specific. [See for example: Wherever they're bad – it's bad [4]

In the UK environment, the Sainsbury Centre focuses on guidance from the National Institute for Health and Clinical Excellence on the management of conduct disorder which suggest that the costs of parenting programs are of the order of $1,000-$1,500 per child for group-based programs.

They extrapolate their calculations to suggest potential lifetime benefits of $375,000 per case for conduct disorder (including $266,000 in reduced offending) and $125,000 per case for sub-threshold conduct problems (including $75,000 in reduced offending).

“The potential benefits of intervention thus exceed costs by several orders of magnitude, implying that, even with very low success rates, intervention may still be justifiable on value for money grounds."

Founded in 1985, the Sainsbury Centre conducts research, policy work and analysis to improve practice and influence policy in mental health as well as public services. Its activity has entered a new phase since its core funder, the UK Gatsby Foundation, announced that it intended to spend out its funds over the course of the next few years.

Reference:
Fergusson D M, Horwood L J, Ridder E M. “Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood” Journal of Child Psychology and Psychiatry 2005; 46(8), pp 837-49

• See also: Bringing children’s services out of the care closet [5]