Summary of the impact

Some 480,000 UK children show persistent antisocial behaviour (Conduct Disorder), a major mental health problem in childhood with strong continuity to adult substance misuse, violence and criminality. Research at King's College London (KCL) showed that these children cost the public ten times more than individuals without Conduct Disorder by age 28. To tackle the problem, KCL researchers were the first to demonstrate that a rigorous parenting programme is a highly effective treatment, even for severe cases. KCL leads the National Academy for Parenting Research which has trained 3,192 practitioners in these approaches, who are estimated to have treated 192,000 troubled children. This success has contributed to the programmes being recommended in NICE guidance and incorporated in a new nation-wide Department of Health-funded rollout reaching 54% of 0-19 year olds in England. The training has also been disseminated internationally.

Underpinning research

Conduct Disorder (CD; defined as `pervasive antisocial behaviour that has lasted at least 6 months, including Oppositional Defiant Disorder') is the most common mental health disorder in children and adolescents, affecting 5% of the population. It causes great impairment to the afflicted child, distress to those around them and has strong continuity to adult substance misuse, violence and criminality. Research on CD, its long term cost and effectiveness of interventions is led at the Institute of Psychiatry, King's College London (KCL) by Prof Stephen Scott (Professor of Child Health and Behaviour, 1990-present) with Prof Martin Knapp (Professor of Health Economics, 1993-present), Dr Thomas O'Connor (1995-2003, Lecturer), Dr Helen Henningham (2008-2009, Research Fellow) and Dr Moira Doolan (Research Therapist, 1995-present).

The high cost of Conduct Disorder: In 2001, KCL researchers were the first in the world to show that individuals with CD have a high financial public cost over the long term into adulthood. The study used empirical service-use data from a large, representative longitudinal survey, rather than theoretical projections. KCL researchers compared the cumulative costs of public services used in an Inner London borough by 154 children with no problems, conduct problems or Conduct Disorder from aged 10 through to adulthood. By age 28, average individual total costs for those with CD were £70,019, compared to £24,324 for the conduct problem group and £7,423 for the no problem group. In all groups, crime incurred the greatest cost, followed by extra educational provision, foster and residential care and state benefits (1). KCL researchers went on to show that the short-term economic cost in childhood was also high. Here, 80 children aged 3-8 years referred to mental health services were studied using the Client Service Receipt Inventory for Childhood. The mean annual total cost was £5,960, mainly due to a high cost burden of £4,637 to the family due to extra time spent on household tasks, the need for repairs and time off work looking after the child. The rest was accounted for by cost to services, mainly the NHS, education and voluntary agencies. Higher cost was predicted by more severe behaviour and being male (2).

Successful treatment of Conduct Disorder: Also in 2001, KCL researchers published the first controlled trial showing that severe CD (the worst 1%) could be successfully treated in everyday practice in the NHS. They administered a behaviourally-based group parent training programme with videotape demonstration of techniques followed by repeated guided practice. Parents of 141 children aged 3-8 referred with antisocial behaviour either received the intervention (n = 90) or acted as waiting list controls (n = 51). Children in the intervention group showed a large, significant reduction in antisocial behaviour with fewer than 50% having a diagnosis of CD by the end of training; those in the waiting list group did not change. Parents in the intervention group gave their children far more praise to encourage desirable behaviour and more effective commands to obtain compliance, than the control parents (3). The improvements were maintained a year later with no loss of effectiveness (4), helping build the case for investment in treatment services.

Having shown that established CD was treatable in `real-life' conditions, the KCL team examined whether prevention in the community was feasible, to avoid the distress and cost of the full-blown disorder. They screened 99% of children (n=650) in 8 primary schools for conduct problems (early signs of CD). Those with an elevated risk (n=112) were entered into a randomised control trial of parenting groups that taught a scientific approach to reading with children in addition to the relationship skills KCL researchers had already proven effective. Reading was added since poor literacy independently predicts worse outcomes. They found a reduction in conduct problems and an improvement in children's reading age by 6 months at age 6 years. This was the first UK trial to show that early intervention was effective for conduct problems and the first in the world to show that a parent-led programme could increase these children's literacy (5).

The effects generalise across ethnic groups: Ethnic minorities are over-represented in those with conduct problems or disorders. There has been concern that `Western' values-based programmes would not be effective with this high-risk group. A 2010 randomised controlled trial by KCL involved parents of children assigned to either the `Incredible Years' preventive program plus a shortened six-week version of the SPOKES literacy program or to usual community services. There were similar enrollment rates across the Black African, African-Caribbean, White-British and Other ethnic groups; 93% said they were well or extremely satisfied, with equally high rates across ethnic groups. At one -year follow-up, those allocated to the intervention showed significant improvements in the parent-child relationship compared to controls; effects were similar across all ethnic groups, showing that ethnic minority families benefitted just as much as white-British families and that the programme was fit for widespread dissemination (6).

References to the research

Grants

• 1996: Department of Health — Randomised controlled trial of parent training groups for childhood conduct disorder, PI: Stephen Scott (£470,000)

• 2002: Economic and Social Research Council — Development of observational & statistical methods to study family effects on child outcomes PI: Thomas O'Connor (£209,000)

• 2003: Healthcare Foundation — Follow-up study of effectiveness of parenting groups for children with conduct problems, PI: Stephen Scott (£300,000)

• 2007: Department for Education — Research programme for National Academy for Parenting Practitioners, PI: Stephen Scott (£10,000,000)

• 2008: Wellcome Trust — Randomised Controlled Trial of teacher classroom management training to prevent conduct problems, PI: Helen Henningham (£170,000)

• 2008: Department of Health — Randomised Controlled Trial of Multisystemic Therapy to reduce conduct problems and avoid public care in adolescents at high-risk, PI Peter Fonagy (£1,030,000)

• 2010: Department for Education — Extension of National Parenting Academy research programme, PI: Stephen Scott (£7,500,000)

Details of the impact

King's College London (KCL) research has led to at least 192,000 children receiving effective treatment for a distressing and impairing condition, thus preventing 50,000 cases of Conduct Disorder (CD), with estimated 25-year savings of £875m (2c). In 2005, following consultation that included three separate presentations of KCL research by Prof Scott to the Prime Minister, the Cabinet Office published its `Respect Action Plan' with a key proposal that the Government should establish a National Parenting Academy to deliver and support high quality parent training; this cites KCL research on the economic impact and effectiveness of parent training (1a). In 2007, KCL won the bid to run the National Academy for Parenting Practitioners and Research (NAPR), with funding of £20m to implement evidence-based programmes, and £10m for research (1b).

Training practitioners in evidence-based interventions: From 2008 to 2010, NAPR organised a large, country-wide training initiative, selecting only proven, evidence-based parenting programmes that were either evidenced by KCL research detailed above, or met the quality criteria developed by KCL researchers. Free training places, and ongoing supervision to refine skills, were allocated to all Local Authorities. Each programme focused on play, praise, incentives, setting limits and discipline, thus promoting sociable, self-reliant child behaviour. The programmes were delivered using a collaborative approach with support provided for parents to practise new approaches during the sessions and through homework, observations of parent and child interactions and ongoing supervision to the therapist to develop their skills (1c). In 2010, the Department for Education (DfE), evaluated the training; the report cites KCL research including Scott et al. 2010a, 2010b (1d) as key evidence supporting the benefits of parenting programmes. Over the evaluation period (Dec 2008 to Mar 2010), 3,162 practitioners from 147 out of 154 Local Authorities attended and completed primary training. Over 95% of participants rated their course as `good' or `very good' and the training resulted in a dramatic increase in the availability of evidence-based parenting interventions across England. Conservatively estimated, by July 2013 at least 192,000 disturbed children have benefitted from this (1,000 trainees delivering 3 groups a year over 4 years to 8 families per group with 2 children per family; figures based on DfE-cited training rates (1d)). This model of dissemination is held to have world-wide relevance, as seen by the leading text on evidence-based therapies for children (editor: John Weisz, Harvard) devoting a chapter to the NAPR training initiative, authored by Prof Scott (1e).

Helping transform practice to become evidence-based: From 2009, each Local Authority in England had appointed a Parenting Commissioner tasked with drawing up a local parenting strategy. Because there are over 150 parenting programmes available in England, NAPR identified the need for each to have an evaluation of its validity and effectiveness in order to inform Commissioners about which are `fit for purpose'. Therefore, KCL researchers at NAPR developed detailed criteria to rate programme quality, evidence-base and dissemination procedures. They then intensively reviewed all programmes available in England in 2009 and found that only 10 were convincingly effective. The ratings are easily accessible on a DfE-hosted website aimed at both Commissioners and parents, which receives 30,000 hits a year, suggesting substantial impact (1f).

Rolling out and evaluating effective programmes for vulnerable groups: KCL research therapists and researchers have developed and tested new parenting programmes. Thus in 2009, the NAPR revised and updated its training for foster parents, a programme called `Fostering Changes', to reflect KCL research findings on how best to develop literacy (Scott et al 2010a), and to reach minority ethnic groups (Scott et al 2010b). Practitioners in 150 out of 154 Local Authorities in England have been trained in the programme. KCL researchers at NAPR evaluated the effectiveness of this training through a randomised controlled trial, and found significant improvements in behaviour problems and attachment security in the children whose foster carers who had received the programme compared to controls (1g,h). The NAPR's Fostering Changes programme has also been disseminated internationally for instance in Austria and New Zealand and their manual translated into German (i,j). In another example, KCL's trial demonstrating the effectiveness of their programme on child literacy (Scott 2010a) contributed to the Education Endowment Fund awarding £1 million to roll out the programme in 45 primary schools affecting 8,100 children in Plymouth and Cornwall (1k).

Impact on national guidance and services: In 2010, the National Institute for health and Clinical Excellence (NICE) invited Prof Scott to chair the development of the Guideline on Antisocial Behaviour and Conduct Disorders. Published in April 2013, it includes repeated references to KCL research, including the parenting trials (Scott et al. 2010a,2010b) and cost-benefit analysis of parenting programmes (Scott et al. 2001 and Romeo et al. 2006) (2a). The Guidelines are effectively mandatory across the NHS, thus having widespread national impact. To give but one example of how they are already being implemented in services by local Health Authorities, the NICE Guidance and KCL research on the cost-effectiveness of parent training programmes (Scott et al. 2001) are cited in the Tower Hamlets Mental Health Strategy published in 2013 (2b). The 2012 Annual Report from the Chief Medical Officer also cites the economic analysis by Scott et al. 2001 as evidence supporting the need for prevention of child mental health problems (2c).

Children and Young Person's Increasing Access to Psychological Therapies (CY-IAPT): CY-IAPT was set up by the Department of Health in 2011 as a service transformation project for Child and Adolescent Mental Health Services to improve collaborative practice between therapists and children, young people and their families with a budget of £54m. Only two therapies are included in the CY-IAPT curriculum: parenting programmes for conduct disorders and cognitive-behaviour therapy for emotional disorders (3b). In 2013-14, 24 new sites will join the CY-IAPT, meaning the programme will reach 54% of the 0-19 population in England. The CY-IAPT website cites NICE Guidance as the principle for selecting parenting programmes for inclusion in the initiative (3c).

Sources to corroborate the impact

1) National Academy for Parenting Practitioners and Research

a. Respect action plan (2005) (p17):
http://tna.europarchive.org/20100413151441/http://www.asb.homeoffice.gov.uk/uploadedFiles/Members_site/Articles/About_Respect/respect_action_plan.pdf

b. Website: http://www.parentingresearch.org.uk/

c. Scott S. National dissemination of effective parenting programmes to improve child outcomes. Br J Psychiatry 2010;196(1):1-3. Doi: 10.1192/bjp.bp.109.067728.

d. Evaluation of the National Academy of Parenting Practitioners' Training (May 2010)
https://www.education.gov.uk/publications/eOrderingDownload/DFE-RR186.pdf

e. Weisz J & Kazdin A (2010) Evidence-Based Psychotherapies for Children and Adolescents (Ch 10). New York: Guilford

f. Searchable website for commissioners with ratings of parenting programmes:
http://www.education.gov.uk/commissioning-toolkit

g. National rollout of Fostering Changes http://www.fosteringchanges.com/fostering_changes

h. Briskman J, et al. (2012) Randomised controlled trial of the Fostering Changes programme:
https://www.gov.uk/government/publications/randomised-controlled-trial-of-the-fostering-changes-programme

i. German translation and dissemination in Austria: documents from "Promente: kinder, jugend, familie" available on request

j. Letter from Infant, Child, Adolescent and Family Mental Health Service, Hutt Valley District Health Board, New Zealand available on request

k. Roll out of the Parent-led improving literacy `SPOKES' reading programme (July 2012):
http://educationendowmentfoundation.org.uk/projects/spokes

2) National Institute for health and Clinical Excellence

a. NICE-SCIE Guidance on the Recognition, Intervention and Management of Antisocial Behaviour and Conduct Disorders in Children and Young People (March 2013):
http://guidance.nice.org.uk/CG158/Guidance/pdf/English

b. Tower Hamlets Mental Health strategy (August 2013)
http://www.towerhamletsccg.nhs.uk/Get_Involved/Evidence%20Reviews%20to%20support%20Tower%20Hamlets%20Mental%20Health%20Strategy.pdf

c. Annual Report of the Chief Medical Offb01cer 2012 (pg 18-19) (published October 2013):
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/252652/33571_2901304_CMO_All.pdf

3) Children and Young Person's Increasing Access to Psychological Therapies

a. CY-IAPT Initiative: http://www.iapt.nhs.uk/cyp-iapt

b. CY-IAPT curriculum (April 2013): http://www.iapt.nhs.uk/silo/files/cyp-iapt-national-curriculum-v6.pdf

c. Key facts briefing: http://www.iapt.nhs.uk/silo/files/cyp-iapt-key-facts-july-2013-.pdf