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One of the “Holy Grails” for mental health researchers and clinicians alike is the ability not only to treat existing behavioral problems effectively but to prevent them. Such a task, however, has proven quite challenging, and some have grown increasingly pessimistic about this goal, especially for at-risk children who at young ages already show signs of early instrumental aggression and rule-breaking behavior. Nevertheless, this remains a noble and important effort given the extraordinary human and financial costs associated with chronic psychopathology and criminal behavior.
One project that has tried to demonstrate success is the Fast Track prevention program. It began in 1991 as a multi-center effort to test whether comprehensive early intervention could prevent later psychopathology and criminal behavior in a group identified as at-risk. A total of 979 kindergarteners from 4 geographic areas were identified as showing early conduct problems. They were then randomized into a control group and an intervention group, the latter of which received social skills training, peer coaching, and academic support over a period of 10 years. The parents also received parental guidance. When the original subjects were 25 year old, they were reassessed for their arrest records as well as for the presence of psychiatric disorders.
As young adults, the rate of a psychiatric or substance abuse diagnosis was 69% in the control group compared to 59% in the intervention group which was a statistically significant difference. Group differences were also found related to crime, risky sexual behavior, and self-esteem. While the overall incarceration rate was not significantly different (6.3% in controls versus 5.0% in the intervention group), the rate of violent and substance-related crime convictions dropped 31% and 35%, respectively. Positive effects of the interventions were not found related to graduation or employment rates and, disappointingly, there was also little effect on how these subjects parented their own offspring.
The overall conclusion of the study was that their intervention did result in a significant reduction in psychopathology and criminal behavior. In the article, the authors advocate strongly that prevention efforts can succeed and should be encouraged.
Of note, this program was reported to cost approximately $58,000 per student and cost analyses are planned for future articles. While this sounds like a hefty price tag, the authors point out that the cost of chronic criminality is estimated at 5.3 million dollars per person.
In looking at these data, I have to say that I was inspired to see a program show clear results. At the same time, it is sobering to see such a major intervention result in rather modest gains. It takes an awful lot of work to drop the rate of psychopathology from about 70% to 60% or to reduce the rate of certain types of crime by 30%. While keeping in mind the limitations involved, it seems critical to continue these efforts. Yes we know already many of the toxic elements that can conspire to keep children down, but how to intervene most effectively when resources are limited remains a critical question that has yet to be answered.
If you made it by reading this far, some of you might be thinking at this point (as I was) something akin to “Why do more research when we know that we can help kids if we just … ended poverty, loved them, protected them from abuse, provided good discipline, etc. The truth, however, is that many children struggle even when these things are present. Then there is that thorny issue of just.”
Author: David Rettew, M.D.