Research Corner: The Public Health Impact of Conduct Disorder

Epidemiologically, huge portions of adolescents engage in serious conduct problems. By their 18th birthday:

empty high school classroom
  • at least 16% of adolescents have been arrested (1)
  • 48% have started drinking (2)
  • 38% have used marijuana (3)
  • 9.5% meet criteria for conduct disorder (4)
  • 7% have dropped out of high school prior to graduation (5)

Without intervention, youth with conduct problems are at risk for adverse outcomes, such as teen pregnancy (6) and chronic unemployment (7), with many progressing to criminal offending or addiction in adulthood (8). Juvenile and adult justice systems and victim-related expenditures cost $194 billion annually (9). Similarly, the total annual cost of substance abuse is $143 billion for alcohol (10) and $181 billion for illicit drugs (11), and there are over 200,000 drug-related deaths each year worldwide (12). Clearly, reducing adolescent involvement in conduct problems is likely to yield great short- (i.e., during adolescence) and long-term (i.e., into adulthood) benefits.
 
Cross-sectional and longitudinal research has found sizeable direct effects of low parental monitoring on the onset and escalation of youth delinquent behavior, substance use, and criminal activity; effects exist for both adjudicated and non-adjudicated delinquent adolescents (13). Low parental monitoring also has indirect effects on youth antisocial behavior, mediated by such factors as association with deviant peers, low self-control, and acceptance of deviant norms (14).
 
Although some have argued that active par tactics (e.g., surveillance, questioning) alienate adolescents and have little effect on behavior problems (15), a recent review concluded that these techniques are especially effective for youth already engaging in conduct-problem behaviors as well as for those who hold weak authority beliefs, engage in few structured activities, or live in high-crime neighborhoods (16). Inconsistent parental discipline also has both direct (17) and indirect (mediated through deviant peer associations) (18) effects on a range of conduct problems. Low parental monitoring and inconsistent discipline are highly intercorrelated and are part of a larger pattern of conflict, negative affect, unclear expectations, and detachment in many families of youth with conduct problems (19).
 
Numerous comprehensive reviews of the literature, conducted by federal (20), international (21) foundation (22), and academic organizations (23) have identified a common set of ESTs for this population; all are family-based. When family-based treatments are compared to individual youth cognitively-oriented treatments, outcomes for family approaches are superior (24). Of these family-based treatments, Multisystemic Therapy (MST; Littell, Popa, & Forsythe, 2005) has the most empirical support. Addressing questions raised about MST’s effectiveness in a previous report (25), a recent methodologically rigorous meta-analysis of 51 outcome studies concluded that MST has at least small (statistically significant) effect sizes on delinquency, substance use, and out-of-home placements, even when poor-quality studies and those that involve another rigorous multimodal treatment as the comparison condition are included (26). Effect sizes were larger in those studies that involved samples of previously-arrested youth (27), who are the intended population for MST and the population served by the MST teams who will participate in the proposed study. The 12 MST randomized clinical trials with juvenile offenders, youth with conduct disorder, and substance-abusing adolescents indicate 26-63% reductions in criminal recidivism, 50-64% decreases in incarcerations/out-of-home placements, improved school attendance, significant decreases in substance use, and significant increases in drug abstinence (28); effects have been shown to last well into adulthood (29).
 
Improved parental monitoring and consistency are the key mechanisms through which reductions in antisocial behavior are achieved in ESTs for conduct-problem youth.  In 2000, researchers Huey, Henggeler, Brondino, and Pickrel examined two samples of adjudicated youth (i.e., violent/chronic offenders and substance-dependent offenders). They demonstrated a four-step mediational pathway between MST adherence, improved parental monitoring/parent-youth communication, decreased deviant peer affiliations, and reductions in delinquent behavior. Similarly, other research (30) found that MST was associated with significant increases in parent supervision which, in turn, predicted reductions in delinquent behavior and drug use. Studies of two other ESTs for this population, Treatment Foster Care-Oregon (TFC-O; Chamberlain, 2003) and Multidimensional Family Therapy (MDFT; Liddle, 2009) have also found that improvements in parental monitoring and discipline practices mediate treatment effects on reducing antisocial behavior among serious juvenile offenders (31) and on decreasing substance use among clinically-referred adolescents (32). Taken together, these studies suggest that improving parental management is essential in treating antisocial and drug-abusing youth.
 
Our Call to Action:
 
EBPI has partnered with MST treatment developer, Scott Henggeler, PhD and MST expert, Cindy Schaeffer, PhD, Associate Professor of Psychiatry, University of Maryland, to aid parents in helping their youth with conduct disorder.
 
Funded by the National Institute of Mental Health (NIMH), we’ve developed and tested a linked parent-youth mobile app system known as VillageWhere for serious juvenile offenders based on MST.
 
VillageWhere features include:

  • a customizable behavior planning interface to mutually specify expectations for prosocial behavior
  • point-reward menus
  • geofencing to designate required and off-limits locations
  • a “find my teen” feature
  • notifications for met and unmet expectations, and brief support videos depicting appropriate parental reactions to challenging adolescent behaviors.

Preliminary pilot research found that VillageWhere was well-liked by and useful to both parents and youth, improved parental management practices, reduced parental stress, and appears promising in improving youth outcomes.
Building on the success of this preliminary effort, EBPI has again been awarded a large (Phase 2) research and development grant from NIMH to continue VillageWhere’s feature development and to eventually conduct a large clinical trial.
 
EBPI is joined by a world-class team of technology and change experts including:

  • David Carroll, MFA, is an Associate Professor of Media Design and Director of the MFA Design and Technology graduate program at Parsons The New School for Design. His research surrounds digital media, especially for mobile devices, towards a critical practice and theory of software and interaction design as social engagement.
  • Edward Deci, PhD, is a Professor of Psychology at the University of Rochester. Dr. Deci developed, studied, and promoted Self-Determination Theory (SDT), a broad and flexible theory of human motivation, throughout his career. Dr. Deci has studied the application of SDT within families, classrooms, teams, organizations, clinics, and cultures, which has generated a massive body of work within the field of SDT and the study of motivation in general.
  • Margaret Wallace, MA, is the CEO at Playmatics and a Gaming & Digital Media Executive Advisor. Margaret Wallace is an entrepreneur focusing on the gaming, tech and digital media sectors. She was named one of the Top 10 Women in Gamification, Fortune's 2014 Ten Powerful Women in Video Games and Forbes Twelve Women in Gaming to Watch.

Our outstanding team of Strategic Advisors includes:

  • Keller Strother, CEO, MST Services, Inc.
  • Sonja Schoenwald, PhD, Professor, Department of Psychiatry, Medical University of South Carolina
  • Joseph Tomassone, PhD, Chief of Treatment Services at the Bureau of Behavioral Health, and Acting Associate Commissioner for Youth Programs & Services in the Division of Juvenile Justice and Opportunities for Youth at the New York State Office for Children and Family Services (NYS OCFS)
  • Thomas J. Hill, JD, Mental Health Policy Director of the Association of Community Human Services Agencies (ACHSA) for Los Angeles County for the past seven years
  • Bradley Beach, Mental Health Clinical Director/Associate Superintendent at Echo Glen Children’s Center
  • Julie Revaz, Manager of Administrative Services at the State of Connecticut, Judicial Branch, Court Support Services Division
  • John Dixon, Associate Commissioner, Close to Home Initiative at City of New York (NYC), Administration for Children’s Services (ACS).

If you work with or have colleagues who work with children with conduct disorder and would like more information or to participate in our research on the VillageWhere project, please contact us at research@ebpi.org.
 
-- Linda Dimeff, PhD
 
 
Citations

  1. Brame, Turner, Paternoster, & Bushway, 2012
  2. Substance Abuse and Mental Health Services Administration, 2014
  3. Substance Abuse and Mental Health Services Administration, 2014
  4. Nock, Kazdin, Hiripi, & C., 2006
  5. Kena et al., 2015
  6. Wymbs et al., 2013
  7. Fergusson, Boden, & Horwood, 2013
  8. Bierman & Sasser, 2014; Loeber, Burke, & Pardini, 2009; Mayes & Suchman, 2006; McCarty et al., 2013
  9. U.S. Department of Justice, 2007
  10. Simon, Patel, & Sleed, 2005)
  11. Office of National Drug Control Policy, 2004
  12. United Nations Office of Drugs and Crime, 2012
  13. Dillon, Pantin, Robbins, & Szapocznik, 2008; Fletcher, Steinberg, & Williams-Wheeler, 2004; Laird, Criss, Pettit, Bates, & Dodge, 2008
  14. Dodge, Greenberg, Malone, & The Conduct Problems Prevention Research Group, 2008; R. L. Simon, Simons, Chen, Brody, & Lin, 2007
  15. Kerr & Stattin, 2000; Stattin & Kerr, 2000
  16. Racz & McMahon, 2011
  17. Gonzales, Pitts, Hill, & Roosa, 2000; Snyder et al., 2010; Stanger, Dumenci, Kamon, & Burstein, 2004
  18. Lansford, Criss, Pettit, Dodge, & Bates, 2003; Lengua, 2006
  19. Bierman & Sasser, 2014
  20. Center for Substance Abuse Prevention (CSAP), 2001; National Institute on Drug Abuse, 1999, 2010; U.S. Public Health Service, 2000, 2001
  21. Early Intervention Foundation, n.d.; "What works for kids: A growing database of evidence-based practice," n.d.
  22. Mihalic & Elliott, 2015
  23. McCart & Sheidow, 2016
  24. McCart & Sheidow, 2016
  25. Littell, Popa, & Forsythe, 2005
  26. van der Stouwe, Asscher, Stams, Dekovic, & van der Laan, 2014
  27. van der Stouwe et al., 2014
  28. Henggeler, 2011
  29. Wagner, Borduin, Sawyer, & Dopp, 2014
  30. Schaeffer et al., 2010
  31. Eddy & Chamberlain, 2000
  32. Henderson, Rowe, Dakof, Hawes, & Liddle, 2009