The Promise of Prevention for Conduct Problems

in At-risk Youth: Findings from the Fast Track Project

Bob McMahonDepartment of PsychologyUniversity of Washington

April 19, 2010

FAST TRACK

Developmental Model

Research Design

Intervention Model

Findings

“EARLY STARTER”DEVELOPMENTAL PATHWAY

Preschool/Early School-Age Onset

Overt and Covert Behaviors

High Degree of Continuity

Poor Prognosis

Enormous Societal Cost“Career Criminal” = $1.3 million (Cohen, 1998)

“EARLY STARTER” PATHWAY TO ANTISOCIAL BEHAVIOR

Preschool Years

Early EducationYears

Early Adolescence

• Early child, family, and community risk factors

• Poor school readiness in cognitive, social, and emotional domains

• Academic failure

• Peer rejection• Social coping

deficits• Adult support/

supervision

• Deviant peers• Poor adult

monitoring• Alienation/

depression

Increased and Diversified Antisocial Behavior

School Entry

Preschool Years

Elementary and Middle School Years

Adulthood

Adolescence• Serious antisocial activity• School drop-out and failure• Substance use• Early/risky sexual activity• Comorbid psychiatric disorders

DEVELOPMENTAL MODEL

Preschool Years

Elementary and Middle School Years

Adolescence

Adulthood• Psychological problems• Criminal behavior• Poor educ/occup adjustment• Marital disruption• Increased mortality

DEVELOPMENTAL MODEL

IMPLICATIONS OF THE DEVELOPMENTAL MODEL FOR

INTERVENTION DESIGN

Multiple Skill Domains

Multiple Socialization Support Systems

Sustained, Well-Integrated

Developmentally and Culturally Informed

FAST TRACK

Developmental Model

Research Design

Intervention Model

Findings

The Fast Track ProjectConduct Problems Prevention

Research Group

Robert J. McMahonUniversity of Washington

Karen L. BiermanMark T. Greenberg

Pennsylvania State University

Kenneth A. Dodge John D. CoieDuke University

Ellen E. PinderhughesTufts University

John E. LochmanUniversity of Alabama

FAST TRACK FUNDING

Fast Track is funded by:• National Institute of Mental Health

With additional support from:• National Institute on Drug Abuse• Department of Education• Center for Substance Abuse Prevention

FAST TRACK SITESSeattle,

WA

Nashville,TN

Durham,NC

Rural,PA

School-Entry Transition

Continuing Support

Middle School Transition

Continuing Support

FAST TRACK TIMELINE

YEAR (1991-1993)

Screening

Implementation

Outcome/Mediators

INTERVENTION

(2005-2007)

ASSESSMENT

Current Age of Sample

Grade

Kg 1-3 4-5 6-7 8-9 10 11-12 20 22AGE

SCREENING AND SELECTION

Teacher Screen 9,594(54 schools, 3 years)

Eligible - Parent Screen 3,600(Top 38%)

Parent Screen 3,267 (91%)

Total Screen Score (T+P) 1,027

Grade 1 at Core School 968 (94%)

High Risk Sample 891 (92%)Control 446 Intervention 445

SAMPLE (4 SITES AND 3 COHORTS)

High-Risk (n = 891) 445 Intervention/446 Control Random Assignment by School 47% Caucasian, 51% African-American,

3% Other 69% Boys, 31% Girls

Normative Community Comparisons (n = 387)

MULTIPROBLEM ASPECTS OF HIGH-RISK SAMPLE

Family Context• Single Parent/Inappropriate Partner

• Family Conflict/Violence

• Substance Abuse

• Personal Adjustment Problems

• “Insular”

• Economically Disadvantaged

Neighborhood Context• High-Risk, Unsafe Neighborhoods

ASSESSMENT MODEL Annual Assessments

Multiple Informants Parent, Teacher, Youth, Peers

Multiple Methods Ratings, Direct Observations, Achievement Tests, Psychiatric Interviews, Sociometrics, School Records, Court Records

Standard Measures Shared with Other National Studies CBC/TRF/YSR, National Youth Survey, C-DISC-4, SACA

FAST TRACK

Developmental Model

Research Design

Intervention Model

Findings

Elementary-School Phase– School-Entry Transition (Grades 1 - 2)– Maintenance and Support (Grades 3 - 5)

Adolescent Phase– Middle School Transition (Grades 5 - 7)– Maintenance and Support (Grades 8 - 10)

PHASES OF INTERVENTION

AREAS OF INTERVENTION(Elementary School Phase)

AcademicAchievement

Child Coping/ProblemSolving

Home-SchoolPartnership

PeerRelations

Parenting &Socialization

ClassroomAtmosphere

INTERVENTION COMPONENTS(Elementary School Phase)

Family

Enrichment Program

School

INTERVENTION COMPONENTS(Elementary School Phase)

Family

Enrichment Program

SchoolPATHS

INTERVENTION COMPONENTS(Elementary School Phase)

FamilyHome Visiting

Enrichment ProgramParent Groups

Friendship GroupsParent-Child Sharing Time

SchoolPATHSTutoring

Peer Pairing

STAFFING RESPONSIBILITIES(Elementary School Phase)

FAMILY COORDINATOR (FC)• Conducts Parent Groups, Parent-Child Sharing Time,

Home VisitsEDUCATIONAL COORDINATOR (EC)

• Conducts Friendship Groups• Consults with Teachers• Supervises Tutors

CLASSROOM TEACHER• Teaches PATHS Lessons

TUTOR• Conducts Reading Tutoring and Peer Pairing

IMPLEMENTATION ISSUES(Elementary School Phase)

Attendance• Flexible Group Times• Familiar Location• Transportation• Child Care• Parents Are Paid Staff Members• Ethnically-Matched Staff• Social Support Among Group Members

STRUCTURE OF ADOLESCENTPREVENTIVE INTERVENTIONS

Standard Interventions(Grades 5-8)

Individualized Interventions (Grades 5-10)

Standard Interventions (Grades 5-8)• All Youth/Families• Monthly Curriculum-Based Parent/Youth

Groups• Normative Challenges of Adolescence• Middle/H.S. Transition Support

• Individualized Interventions (Grades 5-10)

STRUCTURE OF ADOLESCENT PREVENTIVE INTERVENTIONS

Standard Interventions (Grades 5-8)

Individualized Interventions (Grades 5-10)• Assessment of Risk/Protective Factors

• Individualized Skill-Building and Support Services

STRUCTURE OF ADOLESCENT PREVENTIVE INTERVENTIONS

STAFFING RESPONSIBILITIES(Adolescent Phase)

YOUTH COORDINATOR (YC)• Individualized, Criterion-Based Prevention Services• Curriculum-Based Youth and Parent Groups • Home Visits

VOCATIONAL COORDINATOR• Arrange Workshops/Field Trips/Job Shadows

MENTOR• One-on-One Recreational Activities with Youth

TUTOR• Conducts Academic Tutoring

FAST TRACK

Developmental Model

Research Design

Intervention Model

Findings

RESEARCH PARTICIPATION -SAMPLE x SITE (% IN YEAR 11)

Site Intervention Control Normative Durham 94 92 88 Nashville 80 71 77 Pennsylvania 85 75 81 Seattle 83 83 84

Total 85 80 82

DID STRATEGIES WORK?PARTICIPATION IN

PARENT AND CHILD GROUP % Attended

Grade Parent Child

1 96 98

2 88 92

3 80 86

4 73 82

DID STRATEGIES WORK?PARTICIPATION IN

PARENT AND CHILD GROUP

% Attended % Attending > 50% Sessions

Grade Parent Child Parent Child

1 96 98 79 90

2 88 92 79 87

3 80 86 78 84

4 73 82 68 80

INTERVENTION EFFECTSData Analytic Strategy

“Intent To Intervene” Model • “Once Randomized, Always Analyzed”• Regardless of Extent to Which Families

Participated in Intervention, Considered Part of Intervention Sample for Analyses

KEY QUESTIONS

Does Fast Track Work?

How Does It Work?

Does It Work Equally Well for Everyone?

How Much Does It Cost?

Modest Intervention Effects in Multiple Domains Through Elementary School

• Both high-risk (and universal) samples• Effect sizes strongest following initial intensive

prevention efforts• Small to moderate effect sizes maintained with

sustained prevention support

DOES FAST TRACK WORK? Elementary School (Grades 1-5)

Classroom-level Analyses

Peer Sociometrics • Aggression, activity-disruption

Classroom Atmosphere

Prediction of Outcome• Quality of teacher implementation• Dosage (# of lessons) not strong predictor

DOES FAST TRACK WORK? PATHS Universal Intervention

End of Grade 1

CPPRG (1999b)

Youth present throughout Grades 1,2, and 3 (n=2,937)

Aggression (T,P), Academic Engagement (T), Social Competence (T), Hyperactive/ disruptive (P)

Teacher Ratings Moderated by School Environment• Stronger in less disadvantaged schools• ↑ baseline aggression – ↑ effects on aggression

Peer Ratings Moderated by Gender• Effects limited to boys

DOES FAST TRACK WORK? PATHS Universal Intervention

End of Grade 3

CPPRG (2010)

DOES FAST TRACK WORK?Middle School

Do Not Find the Broad Effects on Aggressive and Externalizing Behavior Seen in Elementary School

Lower Levels of Hyperactive Behaviors (Behavioral Inhibition) at Grade 7

More Deviant Peer Involvement in Grades 7 and 8

CPPRG (in press)

KEY QUESTIONS

Does Fast Track Work?

How Does It Work?

Does It Work Equally Well for Everyone?

How Much Does It Cost?

HOW DOES IT WORK?

“Domain-Specific” Effects

MEDIATION OF GRADE 4 OUTCOMES

CPPRG (2002d)

Grade 3 Mediators Grade 4 OutcomesHomeParenting Behavior Change Aggressive/Oppositional

Behavior School Authority Acceptance Peer Social Preference Problems/Prosocial Behavior Change

Social Cognition Hostile Attributions Association with Substance Using Peers (p< .10)

HOW DOES IT WORK?

“Domain-Specific” Effects

Must Address Each Setting in Which the Child Lives

Suggests Importance of Multicomponent Intervention

KEY QUESTIONS

Does Fast Track Work?

How Does It Work?

Does It Work Equally Well for Everyone?

How Much Does It Cost?

Works Comparably for:• Boys and girls• European- and African-American children• Urban and rural communities

DOES IT WORK EQUALLY WELL FOR EVERYONE?

Elementary School

DOES IT WORK EQUALLY WELL FOR EVERYONE?

Elementary School

No Consistent Moderation by:• Demographics

- gender, race, site, cohort• Child variables

- IQ• Family variables

- marital status, SES, parent mental health/substance use• Neighborhood variables

- poverty, instability, quality

HOWEVER – By Grade 9, Effects Depend on Child’s Severity of Risk as Measured 10 Years Earlier During Kindergarten!

DOES IT WORK EQUALLY WELL FOR EVERYONE?

Antisocial Behavior

Highest-Risk Youth (top 3% at Kindergarten) Much Less Likely To:

• Have an externalizing disorder diagnosis - Oppositional defiant disorder, conduct disorder, attention deficit-hyperactivity disorder (ADHD)

• Engage in self-reported antisocial behavior No Intervention Effect for Moderate-Risk

Youth

DOES IT WORK EQUALLY WELL FOR EVERYONE?

Antisocial Behavior in Grade 9

CPPRG, 2007

INTERVENTION EFFECTSGrade 9

DISC Diagnosis of Conduct Disorder

(CPPRG, 2007)*p<.05 (Intervention x Risk Level)

0.04

INTERVENTION EFFECTSGrade 9

DISC Diagnosis of “Any” Externalizing Disorder

(CPPRG, 2007)*p<.05 (Intervention x Risk Level)

0.13

INTERVENTION EFFECTSGrade 9

Self-Reported Antisocial Behavior

(CPPRG, 2007)*p<.05 (Intervention x Risk Level)

1.66

INTERVENTION EFFECTSLifetime Prevalence of Conduct Disorder

(through Grade 12)

0.2

0.41

0.13

0.20

0.00

0.10

0.20

0.30

0.40

0.50

Highest Risk (Top 3% ile)

Moderate Risk (>Top 3% ile)

InterventionControl

Normative

Normative

0.12

CPPRG (in press)

YOUTH ARRESTS Court Record Data Collected Annually

• 6th grade – age 19• Juvenile and adult court records

Searched County of Residence and Surrounding Counties

Lifetime Severity Weighted Frequency• Juvenile arrests• Adult arrests• Self-reported delinquency CPPRG (in press)

ARREST RECORD OUTCOMES

Juvenile Arrests• Court-recorded: odds = 71% of

odds for controls• Moderate-severity arrests: 76% rate

of controls• Onset of arrest: odds = 77% of

controls

CPPRG (in press)

ARREST RECORD OUTCOMES High-Severity Self-reported

Delinquent Behavior• Onset: odds = 82% of controls

High-Severity Adult Arrests• Frequency: Highest-risk youth –

47% fewer arrests compared to controls

• Onset: Effects for ¾ sites; iatrogenic for Nashville

CPPRG (in press)

KEY QUESTIONS

Does Fast Track Work?

How Does It Work?

Does It Work Equally Well for Everyone?

How Much Does It Cost?

HOW MUCH DOES IT COST?

Each Chronic Criminal Costs Society >$1.3 Million (Cohen, 1998)

Fast Track Costs About $5,800/Year Per Child ($58,000 Total)

Cost-Effective for Highest-Risk Children (Top 10%)

• Conduct disorder diagnosis • Index crimes

Foster et al. (2006)

COST SAVINGS DUE TO INTERVENTION (PER CHILD)

Low 90% Top 5-10% Top 5%

Parent and youth report (SACA; Grades 9-12)

General Health Services Odds Ratio• General health provider .77• Pediatrician .78• Emergency department .78• Gen health provider-Mental health .64

Mental Health Services• Outpatient MH services (Gr 11-12) .52• Inpatient MH services NS

DOES FAST TRACK WORK? Health Services Use

Grades 9-12

Jones et al (2010)

Modest Intervention Effects in Multiple Domains Through Elementary School• Both high-risk and universal samples• Effect sizes strongest following initial

intensive prevention efforts• Small to moderate effect sizes maintained

with sustained prevention support In Contrast to Elementary School,

Minimal Intervention Effects in Middle School

SUMMARY

Mediation Analyses Indicate Domain-Specific Effects • Suggests importance of multicomponent

intervention

Effects Generalizable Across Gender, Ethnicity, Site, Etc. During Elementary and Middle School

SUMMARY (cont.)

However, During High School, Emerging Moderation of Effects Based on Severity of Initial Risk for Some Outcomes

Strong Intervention Effects on Conduct Disorder Diagnosis Through Grade 12 for Highest-Risk Youth

Strong Intervention Effect for Juvenile Arrests

SUMMARY (cont.)

Although Expensive, Fast Track is Cost-Effective for Most At-Risk Youth

Not Only in Terms of ↓ Dx of Externalizing Disorders, But ↓ Use of General Health and Outpatient MH Services During Adolescence (Jones et al., 2010)

SUMMARY (cont.)

CURRENT/FUTURE DIRECTIONS

Continued Analysis of Intervention Effects Through Age 20

Economic Analyses Analysis of DNA/Identification of

Candidate Marker Genes Contact Sample at Age 25 Dissemination Efforts

CURRENT/FUTURE DIRECTIONS ARRA Admin Supplement (Witkiewitz)

• Developmental pathways of conduct problems

• Role of callous-unemotional traits as predictor of youth outcomes and/or moderator of FT intervention

ARRA Challenge Grant (King, Witkiewitz)• Identify Krueger’s “externalizing spectrum” in

childhood and adolescence?

ADDITIONAL INFORMATION

Fast Track website:http://fasttrackproject.org

Contact:Bob McMahon Phone: (206) 685-9127University of Washington FAX: (206) 685-3944Department of PsychologyBox 351525Seattle, WA 98195-1525

Email: mcmahon@u.washington.edu