We need to invest in early intervention services to improve lives and save money

May 7, 2015

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Dr Sajid Humayun, Senior Lecturer in Psychology at the University of Greenwich, writes about a recent letter in the press from charities saying that early interventions to stop young people getting into serious difficulties could save £1.7bn a year:

Persistent antisocial behaviour is remarkably common. In its most severe form as a diagnosable mental disorder, such as conduct disorder, it affects 5 per cent of the population and lower levels of conduct problems affect many more children.

The consequences of these problems can be very serious. 90 per cent of children with persistent conduct problems have another mental health problem and they are ten times more likely to have Attention Deficit Hyperactivity Disorder (ADHD).

There is a high continuity to adult criminality and these children are more likely to leave school without qualifications, end up unemployed, misuse drugs and become a teenage parent. In fact, conduct disorder is the most reliable precursor to a range of adult mental health problems and a child with conduct disorder aged 10 will cost society 10 times as much as one without it by the time they are 28.

So we should welcome the letter published in the Independent yesterday written by some of the country’s leading charities. In it they urge the next government to invest in early intervention services to both improve children’s lives and to save the taxpayer money in the long run.

They argue that it will cost less to prevent problems like conduct disorder than it will do to try to treat them and deal with the consequences of them further down the line. There is certainly plenty of evidence to support this argument, with some early prevention approaches showing large long-term cost benefits for a relatively small early investment. In fact some governments, such as Washington State in the US, have embedded this principle into their statewide policies with the aim of reducing crime so much in the long-term that they can avoid building new prisons.

It is also the case that the causes of lifetime antisocial behaviour and criminality can be found in childhood and adolescence and that interventions can be effective. For example, helping parents with their parenting and managing their child’s behaviour is highly effective in reducing childhood antisocial behaviour and parenting programmes are recommended by NICE as the intervention of choice for conduct disorder in children under the age of 12.

However, we must be clear what we mean by effective interventions. There are plenty of approaches being used by individuals and groups with children’s best interests in mind, and that on paper look like they should work, but have not been shown to work. Many of these will not work when tested properly. Given the number of evidence-based interventions available (as recently reviewed by the Early Intervention Foundation reports), there really is no excuse in investing public funds in untested interventions.

Furthermore, even evidence-based interventions sometimes do not work. There are a number of reasons for this. First, delivering the programme in the way it was designed to be delivered has been shown to predict whether children benefit, and therapists who fail to adhere to programme guidance properly can actually make things worse. So whilst it is tempting to adapt American programmes to make them more suitable for British families, this should be done with great care. Second, there is no substitute for skill. Effective intervention is hard to do and the skill of therapists has been shown to predict children’s outcomes. Skilled therapists cost more, so the next government must be willing to invest more to ensure that children benefit.

Third, evidence for most of these interventions comes from the US and sometimes even the best interventions have not exported successfully. Why is not always clear, but one possible explanation is what programmes are being compared to. Typically, the effectiveness of interventions is judged by comparing them to usual ‘services’ for children and young people. If those ‘services’ do more harm than good (for example, imprisonment) then almost any intervention will do better. What this means is that when we provide a new intervention in this country we must also test it using high-quality evaluation research.

Fourth, even wide-scale prevention efforts need to be somewhat targeted. Yes, the next government needs to spend more than is currently being spent on prevention services, but money will always be tight. So we should try to ensure that it is the children and families who will benefit most from prevention programmes that are the ones who receive those programmes. How do we do this when we are aiming to prevent problems that haven’t appeared yet? We do so by conducting research to identify the causes of these problems and ways to spot risk factors early. This requires high quality, ideally longitudinal, research and we are simply not doing enough of that in this country at the moment.

Further reading:

Aos, S., Miller, M., & Drake, E. (2006). Evidence-based public policy options to reduce future prison construction, criminal justice costs, and crime rates (Vol. 19). Olympia: Washington State Institute for Public Policy. http://heinonlinebackup.com/hol-cgi-bin/get_pdf.cgi?handle=hein.journals/fedsen19&section=55

Beecham, J. (2014). Annual Research Review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders. Journal of Child Psychology and Psychiatry, 55(6), 714–732.

Humayun, S., & Scott, S. (2015). Evidence-based interventions for violent behavior in children and adolescents. In J. Lindert & I. Levav (Eds.), Violence and Mental Health: Its Manifold Faces (pp. 391–420). New York: Springer.

NICE. (2013). CG158 Conduct disorders in children and young people: NICE guideline [Guidance/Clinical Guidelines]. http://publications.nice.org.uk/antisocial-behaviour-and-conduct-disorders-in-children-and-young-people-recognition-intervention-cg158

Scott, S., & Humayun, S. (2011). Parenting Programmes for Conduct Problems. In D. Skuse, H. Bruce, L. Dowdney, & D. Mrazek (Eds.), Child Psychology and Psychiatry: Frameworks for Practice, Second Edition (pp. 271–275). John Wiley & Sons.

Welsh, B. C., & Farrington, D. P. (2011). The Benefits and Costs of Early Prevention Compared With Imprisonment Toward Evidence-Based Policy. The Prison Journal, 91(3 suppl), 120S–137S.