EVIDENCE TO THE GRAHAM ALLEN REVIEW ON EARLY INTERVENTION DELIVERY
David Utting
Secretary to the Independent Commission on Youth Crime and Antisocial Behaviour
Email address:
Website: www.youthcrimecommission.org.uk
Introduction
The Independent Commission on Youth Crime and Antisocial Behaviour, chaired by Anthony Salz, published its report Time for a fresh start in July 2010. It sets out a strategic blueprint for reforming the response to antisocial behaviour offending and offending by children and young people based on key underlying principles of:
§ prevention (addressing the underlying circumstances and needs in children and young people’s lives)
§ restoration (ensuring that children and young people responsible for antisocial behaviour and offending face meaningful consequences that hold them accountable for harm causes to victims and the wider community)
§ integration (seeking to retain children and young people who offend within mainstream society and reconnect them in ways that enable them to lead law-abiding lives.
A copy of the full report and its executive summary are enclosed with this submission. However, our comments relate only to the first of these principles, which is of particular relevance to the Review.
On its own terms, the Commission has concluded that:
§ prevention and early intervention should be given a higher profile in tackling crime and antisocial behaviour.
§ an understanding of risk and protective factors in children and young people’s lives provides a valuable basis for understanding how preventive services produce positive results and for planning and evaluating strategies.
§ Although there is more to be learned about causal pathways, there is already more than enough knowledge about relevant factors and promising interventions to justify early intervention as part of a public health approach to promoting children’s welfare.
§ Research has highlighted a growing range of preventive interventions capable of reducing persistent, severe childhood behaviour problems. In the United States, saving ratios of between 2 to 1 and 17 to 1 have been calculated for preventive programmes, including a number that are also available in England and Wales.
§ A structured programme of investment is needed in the most promising preventive approaches, including ‘universal’ services as well as targeted prevention.
§ There should be particular emphasis on reaching children who exhibit severe, persistent behaviour problems from an early age, and their families.
§ Investment in prevention has the strong potential to save money in the medium and longer-term for taxpayers. To achieve this, it must be accompanied by systematic arrangements for sharing information about effective practice and delivery.
Other areas of the Commission’s report – especially those relating to the ineffective and very expensive use of youth custody – highlight the scope that exists for substantial savings in public spending over a relatively short timescale. The Commission’s strong endorsement of the case for effective early intervention is supported by its view that cost reductions elsewhere can be extended and compounded by reinvesting some of the money saved in preventive services.
It is in this context that we have sought to answer the specific questions posed by the Review.
1) What are the likely causes of impairments to children’s social and emotional capability? And how common are they across the population?
The international evidence from longitudinal surveys and other research studies suggests multiple, interacting causes of impaired social or emotional functioning, rather than any one ‘cause’ that can be singled out and targeted. In the case of severe and persistent behaviour problems – an area of specific interest to the Independent Commission on Youth Crime and Antisocial Behaviour – the available research identifies a wide range of factors associated with increased risk that children will exhibit or develop chronic behaviour problems. It also points to factors that are protective or ‘promotive’, in the sense that their existence reduces children’s exposure to risk in otherwise adverse circumstances. Risk and protective factors can usefully be categorised and considered in different domains: notably those relating to the individual child (some genetically related or influenced, such as gender and temperament, and others that are more obviously malleable, such as antisocial attitudes), to families, to schools and to the wider community. This indicates that preventive interventions, in order to be effective, will often need to reach ‘at risk’ children in more than one setting or domain.
It is also important to understand that risk factors – although they may be implicated in chains of causation – are not necessarily causes themselves. Some are proxy indicators of risk that serve little practical preventive value, beyond their capacity to serve as a marker (for example, children and young people indicating gang affiliation through clothing). Others can be seen to operate indirectly or at a distance from an immediate cause of problem behaviour; for example, family poverty may chiefly influence children’s behaviour through the stress it places on parents and parenting. Closer causal relationships appear most probable in circumstances where a risk factor concerns a child’s direct, personal relationships. A key example would be the well-established link between children’s antisocial behaviour and harsh, inconsistent discipline and poor supervision by parents. Evidence from parenting interventions that have led to improvements in children’s behaviour by improving parenting skills provides clinching evidence of causation.
Given the implied need for intervention in overlapping domains, the Youth Crime Commission found the case for a ‘public health’ approach to the prevention of childhood behaviour problems was compelling. This recognises the imperfect state of knowledge concerning causes (and chains of causation) by working across whole communities (or populations) to reduce multiple risk factors in different areas of children’s lives. Effective interventions like the Incredible Years and Triple P parenting programmes work in practice by reducing risk factors such as harsh physical discipline and promoting protective factors such as the parent praising and modelling positive behaviour. The Commission’s view, set out in its report Time for a fresh start, is that whole communities should be working to assess and lower the levels of risk to which children are exposed. Although focused on youth crime and antisocial behaviour, the Commission also recognises that a similar, overlapping range of risk factors relate to children and young people’s experiences of (or later involvement in) problems that include underachievement in school, poor mental health, alcohol and drug misuse and precocious sexual activity, including teenage pregnancy. This reinforces the case for a public health approach to prevention and early intervention.
From its particular standpoint, the Commission has also highlighted research evidence that children who exhibit severe and persistent behaviour problems from an early age are disproportionately likely to develop into severely antisocial adolescents and adults. Time for a fresh start cites the estimate by Dr Stephen Scott of the Institute of Psychiatry that some 15% of five-year olds exhibit behaviour that is persistently more oppositional and defiant than usual for their age (See chart below). By age eight, around a fifth will have moved within a normal range, while a smaller group who did not previously exhibit persistent antisocial behaviour will now do so. This process continues into adolescence. Thus by age 17, the proportion who have diagnosable conduct disorders will have declined to around 5% or 6%. The fact that most children who are persistently antisocial at age five do not go on to become severely antisocial young adults emphasises the importance of taking care not to stigmatise young children as ‘potential criminals’ when early interventions are offered. Nevertheless, it is the Commission’s view that the evidence concerning continuities in chronic antisocial behaviour creates crucial and underexploited opportunities for prevention, given that 40 per cent of children with diagnosed conduct disorders will grow into psychosocially disturbed adults unless effective treatment is made available.
References:
Independent Commission on Youth Crime and Antisocial Behaviour (2010) Time for a fresh start. London: Police Foundation / www.youthcrimecommission.org.uk
Hawkins, J.D., Welsh, B.C. & Utting, D. (2010) ‘Preventing youth crime: evidence and opportunities’. In D.J. Smith(ed.) A New Response to Youth Crime. Cullompton, Devon: Willan.
Rutter, M. (2010) ‘Causes of offending and antisocial behaviour’. In D.J. Smith(ed.) A New Response to Youth Crime. Cullompton, Devon: Willan.
Farrington, D.P. & Welsh, B.C. (2007) Saving Children from a Life of Crime. Oxford: Oxford University Press.
Coid, J.W. (2003) ‘Formulating strategies for the primary prevention of adult antisocial behaviour: ‘high risk’ or ‘population’ strategies? In D.P. Farrington & J.W. Coid (eds.) Early Prevention of Adult Antisocial Behavior. Cambridge: Cambridge University Press.
2) Do we know how to improve children’s social and emotional capabilities in a cost-effective way?
The simple answer is ‘yes’, but most of the evidence concerning cost-effectiveness relates to interventions that have been evaluated in the United States. The ability to assess the cost-effectiveness of individual interventions depends not only on whether their outcomes have been evaluated, but also on whether they were compared with outcomes for a valid group of children who received no intervention, ‘treatment as usual’ or some alternative service. Evaluations using comparison designs (whether ‘experimental’ or ‘quasi-experimental’) have not been commonly used in the UK to evaluate preventive, social interventions with children. It is also notable that the best-evidence approaches in Britain often relate to programmes whose promise was first demonstrated overseas: for example, Family-Nurse Partnerships (Olds), The Incredible Years (Webster-Stratton), Triple P (Sanders) Multi-dimensional treatment foster care (Chamberlain), Functional Family Therapy (Alexander and Parsons) and Multi-systemic Therapy (Henggeler).
Even in America, the effectiveness of preventive programmes is often ‘unknown’ because they have never been rigorously evaluated. However, the long-term follow-up data from the evaluation of the High-Scope Perry Pre-school Programme in Michigan demonstrates how potent cost-effectiveness data can be in arguing the case for early intervention (not least when a wide range of costs to the taxpayer are assessed). The model of greatest potential value in the UK is, however, the work of Steve Aos and colleagues at the Washington State Institute for Public Policy whose work on cost-effectiveness has played a significant part in re-directing state policy and funding towards early intervention programmes that can achieve medium to long-term savings that are substantially greater than the costs of introducing and running them.
In Time for a fresh start, the Independent Commission strongly advocates the establishment of a comparable institute or organisation in England and Wales to provide an authoritative source of information and practical advice on the most promising services and programmes in preventing youth crime and antisocial behaviour, including calculations of cost effectiveness.
References:
Hawkins, J.D. and others (2010) as above
Olds, D. L., Eckenrode, J., Henderson, C. R., Jr., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L. M. and Luckey, D. (1997) ‘Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial, Journal of the American Medical Association, 278:8, pp. 637-643.
Webster-Stratton, C. and Taylor, T. (2001) ‘Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0 to 8 Years)’, Prevention Science, 2:3, pp. 165-192.
Sanders, M. R., Markie-Dadds, C. and Turner, K. M. (2003) Theoretical, scientific and clinical foundations of the Triple-P Positive Parenting Program: A population approach to the promotion of parenting competence. Parenting Practice and Research Monograph No 1 (Parenting and Family Support Centre, University of Queensland).
Chamberlain, P. (2003) Treating chronic juvenile offenders. Advances made through the Oregon Multidimensional Treatment Foster Care model (Washington, DC: American Psychological Association).
Alexander, J. F. and Parsons, B. V. (1973) ‘Short-term behavioral intervention with delinquent families: Impact on family process and recidivism’, Journal of Abnormal Psychology, 81:3, pp. 219-225.
Henggeler, S. W. (1998) Blueprints for Violence Prevention: Multisystemic Therapy (Boulder: Centre for the Study and Prevention of Violence).
Schweinhart, L. J., Montie, J., Zongping, X., Barnett, W. S., Belfield, C. R. and Nores, M. (2005) Lifetime effects: The High/Scope Perry Preschool study through age 40 (Ypsilanti, MI: High/Scope Press)
Aos, S., Lieb, R., Mayfield, J., Miller, M. and Pennucci, A. (2004) Benefits and costs of prevention and early intervention programs for youth (Olympia, WA: Washington State Institute for Public Policy).
3. If we know how to improve children’s capabilities in a cost effective way, why are we not doing so? What is the split between universal schemes and specific schemes?
a) A whole range of factors have inhibited the adoption of cost-effective practice of which access to necessary funding – although often cited – is only one. To list only a few, they include:
§ A political and media-fuelled emphasis on crisis intervention (notably in relation to child abuse) that has reinforced a risk-averse culture among service planners who have treated investment in prevention as a lower priority.
§ The way that early intervention services (and their potential benefits) cross professional and departmental boundaries with consequent difficulties in agreeing responsibilities for budgets, service planning, commissioning and delivery. Children’s Trusts or comparable partnership arrangements between education, children’s care services, health and other functions are, in the Commission’s view, an essential element in overcoming these barriers at local level. Policy making between relevant departments in central government needs, similarly, to be carefully coordinated.
§ A tendency for national and local policy makers to demand higher standards of evidence from those proposing new interventions, than they apply to existing approaches for which there is little or no supporting evidence of effectiveness.
§ Reluctance among local policy makers to embrace cost-effective evidence-based practice in preference to their existing ‘home-grown’ approaches, or to accept that good practice develop elsewhere can ‘work’ in their own area (‘not invented here’).
§ Reluctance among middle-managers and front-line practitioners to embrace change and to adapt their skills to implement new and unfamiliar approaches.
§ Short-term horizons in the public sector, often driven by political cycles, that have tended to result in a short-term ‘project-based’ approach to funding and undue emphasis on achieving ‘quick wins’ in preference to medium and long-term outcomes.
§ Failure to adequately evaluate preventive services (or to evaluate them too early in their lifetime to produce credible results) reinforcing a failure to understand how effective interventions can best be implemented or to learn from failures before terminating on project and moving on to the next (seemingly) ‘good thing’.