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QUESTION: In children at high risk of developing long term antisocial behaviour, can a multicomponent preventive programme (Fast Track) improve social, emotional, and academic skills?
Primary schools in neighbourhoods with high rates of delinquency and juvenile arrests in 4 US regions.
891 children (mean age 7 y, 69% boys) who had completed 1 year of kindergarten and were behaviourally disruptive (ie, had high scores on teacher and parent ratings of behaviour problems).
54 schools matched for size, poverty, and ethnic composition were allocated to the intervention (445 children in 191 classrooms) or control (446 children in 210 classrooms) conditions. The intervention consisted of a curriculum (Promoting Alternative Thinking Strategies [PATHS]), parent groups, child social skills training groups, parent child sharing time, home visiting, child peer pairing, and academic tutoring and was given during school and 2 hour extracurricular enrichment programmes and in the home.
Main outcome measures
Child social cognition and reading, child peer relations and social competence, parenting behaviour and social cognition, and child aggressive and disruptive behaviour. These were based on both reports and direct, independent observation.
At 1 year, the preventive programme led to improved outcomes for child social cognition and reading (effect sizes 0.23 to 0.54, p≤0.04); child peer relations and social competence (effect sizes 0.27 to 0.28, p<0.02); parenting behaviour (effect sizes 0.23 to 0.32, p≤0.03); and child aggressive and disruptive behaviour (effect sizes 0.26 to 0.31, p≤0.02) compared with no intervention; the effect sizes are shown for outcomes with ≥80% follow up. The effect sizes for measures of parenting behaviour and social cognition with ≥80% follow up were not statistically significant.
In children at high risk of developing long term antisocial behaviour, the Fast Track preventive programme improved some measures of social, emotional, behavioural functioning, and academic skills at 1 year
The Fast Track Prevention Trial is a large carefully done study aimed at preventing conduct problems. It has many strengths. The design was strong: a randomised controlled trial with the unit of assignment being an entire school. The intervention programme was guided by a well developed model of the development of antisocial behaviour in children. The programme consisted of 7 elements (6 targeted elements and 1 universal element) that focused on the children, the parents, and the teachers. The assessment procedures included data from the children themselves, parents, teachers, and peers. A combination of paper and pencil reports (eg, checklist data) and observational data (eg, behavioural observations in school) were used. The positive outcomes were reported not only by parents, teachers and children but by independent observations as well.
After only 1 year of intervention, modest positive results were seen. The results were mixed, however, with parent and teacher behavioural ratings showing no differential problem reduction between groups, but independent observations showed substantial improvements in disruptive behaviour in the intervention group in the school but not in the home.
It is too early to know whether the intervention will be successful in bringing about clinically important levels of reduction in antisocial behaviour in these high risk children (ie, reductions of a magnitude and consistency that would be meaningful to clinicians). As the study progresses, the answer to this question will become more apparent. One of the challenges the investigators face in subsequent years is to keep attrition rates low. Those rates are not presented as clearly as they might be in the present reports.
Placing this study in the context of lowering the burden of suffering from antisocial behaviour in children and adolescents is important. In a community sample, if the presence of early externalising behaviour assessed by currently available measures is used to designate kindergarten and first grade children in normal populations as high risk for later antisocial behaviour, the level of misclassification will be substantial.1 At least one half of the children who develop clinically important antisocial behaviour later on will not be picked up by the initial screen. Furthermore, ≥50% of the children who receive the intervention may not need it and may be subjected to the negative effects of labelling. Thus, the predictive accuracy of a one time screen imposes a disadvantage on the potential effect of early intervention programmes to prevent antisocial behaviour in children and adolescents. A promising approach is to move away from identifying a predictor at 1 point in time and to move towards continuous risk assessments over time.2
Another important issue with this study is the extent to which it will be disseminated and maintained in other settings if it proves to be effective. Two points are relevant here. First is the cost of study.3 Eventually, data from an economic analysis will be needed to convince school authorities and others that although this intervention is expensive (we do not know how expensive yet), it is worthwhile because it reduces downstream costs (eg, special class placements and vandalism). A second point is the acceptability of the study by school boards and individual schools. It may be that a school willing to take on such a programme is already on a positive trajectory anyway.4 Certainly, considerable demands are placed on a participating school in implementing such a programme (and a programme in which they seem to have had little developmental input). In this regard, it would be important to know how many schools turned down the initial request to participate in the study.
The Fast Track Prevention Trial is an important initiative. It will show the extent to which children identified as being antisocial early, on the basis of parent and teacher checklist information, can be helped to modify their behaviour by an intensive and expensive intervention programme. Provided the reductions in the levels of antisocial behaviour are of a magnitude that would be meaningful to clinicians, the challenge then for the investigators will be to develop strategies to ensure the programme can be disseminated and maintained in various settings. This will certainly require the costs of the programme to be known and probably will necessitate finding ways to reduce costs and to ensure that the programme is widely acceptable to schools.
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