London school trial speaks well for SPOKES

Were it possible to design a population-based intervention to tackle early-onset antisocial behavior, the savings, by any social, medical or financial reckoning, would be prodigious.

The lifetime cost of answering the needs of a single high-risk young person has been calculated to be around $2m; individuals diagnosed with a conduct disorder at the age of ten cost society ten times as much by the time they are 28 as those without. Dismaying figures at least strengthen the case for investment in solutions.

Early diagnosis and treatment are crucial but the current UK formula does not achieve either. Only around a quarter of cases meeting ODD/CD (Oppositional Defiant Disorder/Conduct Disorder) criteria get specialist help. Much specialist treatment rooted in psychotherapy is unproven and delivered too late; programs that work inside university clinics too often do not perform in real world practice.

The altogether gloomy picture is part of the background included in a report on work by Stephen Scott and colleagues at the Institute of Psychiatry. It gives a strong hint as to the better potential of a primary school intervention targeting four risk factors: ineffective parenting, conduct problems, attention deficit/hyperactivity disorder (ADHD) symptoms, and low reading ability.

Its originality lies in its attempt to address multiple risk factors and to screen the whole school population in a deprived area to identify children at risk.

A randomized controlled trial was carried out in eight London schools. Just short of 950 six-year-old children were screened for antisocial behavior. Parents of 112 high scorers were randomly allocated to parenting groups held in schools or to a control group. The progress of 109 children was followed up a year later.

The 28-week intervention included proven components to address both child behavior (12 weeks of Incredible Years) and child literacy (through a new 10-week SPOKES program to help parents read with their children). Control group participants were given information about a telephone helpline advising them how to obtain regular services.

Fidelity of implementation – a known weakness in existing services – was emphasized as part of training and supervising therapists. Conduct problems were assessed by means of parent interview, parenting skills by direct observation, and child reading by psychometric testing.

Scott and his team report that, at follow-up, parents allocated to the intervention made good use of play, praise and time-out more often than those in the control group. They resorted less often to harsh discipline. Effect sizes ranged from .31 to .59 sd (p-values .046 to .005).

Compared to control children, whose behavior didn't change, intervention children's conduct problems reduced by .52sd, dropping from the 80th to the 61st percentile; oppositional-defiant disorder (ODD) was halved from 60% to 31% (p = .003). ADHD symptoms were reduced by .44sd (p = .002), and reading age improved by six months (.36sd, p = .027). Teacher-rated behavior did not change.

The findings were taken as a clear indication that population-based early interventions were practically feasible. A suitably crafted program should be able to reach a substantial proportion of parents, busy and stressed as they might be (although 60% of families with children at risk did not engage). Even at $3,800, the cost per child was much cheaper than long-term costs associated with persistent antisocial behavior.

• Supporting Parents on Kids Education in Schools (SPOKES) has been renamed Helping Children Achieve (HCA) to avoid confusion with an earlier initiative also led by Stephen Scott and Professor Kathy Sylva [1] at Oxford University. They argue that behavioral and learning disorders in children tend to go hand-in-hand, but little is known about how treatments for behavioral difficulties affect children's literacy, and vice versa. They say their intervention is the first in the UK and Europe to combine a parent training curriculum with a parent literacy program.

See: Scott S, Sylva K, Doolan M, Price J, Jacobs B, Crook C and Landau S, “Randomized controlled trial of parent groups for child antisocial behavior targeting multiple risk factors: the SPOKES project” Journal of Child Psychology and Psychiatry51, 1 pp 48-57.