IV. Family-Based Prevention
The behavioral parent management training developed by Gerald Patterson (1982) in Oregon is one of the most influential family-based prevention approaches. His careful observations of parent–child interaction showed that parents of antisocial children were deficient in their methods of child rearing. These parents failed to tell their children how they were expected to behave, failed to use punishment consistently or monitor their behavior to ensure that it was desirable, and failed to enforce rules promptly and unambiguously with appropriate rewards and penalties. The parents of antisocial children used more punishment (such as scolding, shouting, or threatening), but failed to use it consistently or make it contingent on the child’s behavior. Patterson’s (1982) method involved linking antecedents, behaviors, and consequences. He attempted to train parents in effective child-rearing methods, namely, noticing what a child is doing, monitoring the child’s behavior over long periods, clearly stating house rules, making rewards and punishments consistent and contingent on the child’s behavior, and negotiating disagreements so that conflicts and crises did not escalate. His treatment was shown to be effective in reducing child stealing and antisocial behavior over short periods in small-scale studies. However, the treatment worked best with children aged 3 to 10 and less well with adolescents. Also, there were problems achieving cooperation from the families experiencing the worst problems. In particular, single mothers on welfare were experiencing so many different stresses that they found it difficult to use consistent and contingent child-rearing methods. The most important types of family-based programs that have been evaluated will now be reviewed. These are home visiting programs (and especially the work of Olds and Arthur Reynolds), parent training programs (especially those used by Carolyn Webster-Stratton, Stephen Scott, and Matthew Sanders), home or community programs with older children (especially those implemented by James Alexander and Patricia Chamberlain), and Multi-systemic Therapy or MST (used by Scott Henggeler and Alison Cunningham).
A. Home Visiting Programs
In the most famous intensive home visiting program, Olds and his colleagues (Olds, Hill, & Rumsey, 1998) in Elmira (New York) randomly allocated 400 mothers to receive home visits from nurses during pregnancy, to receive visits both during pregnancy and during the first 2 years of the child’s life, or to be part of a control group that received no visits. Each visit lasted about 1.25 hours, and the mothers were visited on average every 2 weeks. The home visitors gave advice about prenatal and postnatal care of the child, about infant development, and about the importance of proper nutrition and avoiding smoking and drinking during pregnancy. Thus, this was a general parent education program. The results of this experiment showed that the postnatal home visits caused a decrease in recorded child physical abuse and neglect during the first 2 years of life, especially by poor unmarried teenage mothers; 4% of visited versus 19% of nonvisited mothers of this type were guilty of child abuse or neglect. This last result is important because children who are physically abused or neglected tend to become violent offenders later in life. In a 15-year follow-up, the main focus was on lower-class unmarried mothers. Among these mothers, those who received prenatal and postnatal home visits had fewer arrests than those who received prenatal visits or no visits. Also, children of these mothers who received prenatal and/or postnatal home visits had less than half as many arrests as children of mothers who received no visits. According to Steve Aos and his colleagues (Aos, Phipps, Barnoski, & Lieb, 2001) from the Washington State Institute for Public Policy, $3 were saved for every $1 expended on high-risk mothers in this program. Like the Perry project, described later in this research paper, the Child Parent Center (CPC) in Chicago provided disadvantaged children with a high-quality, active learning preschool supplemented with family support. However, unlike Perry, CPC continued to provide the children with the educational enrichment component into elementary school, up to age 9. Focusing on the effect of the preschool intervention, Reynolds and his colleagues (Reynolds, Temple, Robertson, & Mann, 2001) found that compared to a control group, those who received the program were less likely to be arrested for either nonviolent or violent offenses by the time they were 18. The CPC program also produced other benefits for those in the experimental compared to the control group, such as a high rate of high school completion.
B. Parent Management Training
One of the most famous parent training programs was developed by Carolyn Webster-Stratton (2000) in Seattle. She evaluated its success by randomly assigning 426 4- year-old children (most with single mothers on welfare) either to an experimental group that received parent training or to a control group that did not. The experimental mothers met in groups every week for 8 or 9 weeks, watched videotapes demonstrating parenting skills, and then took part in focused group discussions. The topics included how to play with your child, helping your child learn, using praise and encouragement to bring out the best in your child, effective setting of limits, handling misbehavior, how to teach your child to solve problems, and how to give and get support. Observations in the home showed that the children of mothers in the experimental group behaved better than those of the control group mothers. Webster-Stratton and Mary Hammond (1997) also evaluated the effectiveness of parent training and child skills training with about 100 Seattle children (average age, 5) referred to a clinic because of conduct problems. The children and their parents were randomly assigned to (a) receive parent training, (b) receive child skills training, (c) receive both parent and child training, or (d) be in a control group. The skills training aimed to foster prosocial behavior and interpersonal skills using video modeling, while the parent training involved weekly meetings between parents and therapists for 22 to 24 weeks. Parent reports and home observations showed that children in all three experimental conditions had fewer behavior problems than control children, in both an immediate and a one-year followup. There was little difference in results among the three experimental conditions, although the combined parent and child training condition produced the most significant improvements in child behavior at the 1-year follow-up. It is generally true that combined parent and child interventions are more effective than either one alone. Scott and his colleagues (Scott, Spender, Doolan, Jacobs, & Aspland, 2001) evaluated the Webster-Stratton parent training program in London and Chichester, U.K. About 140 mainly poor, disadvantaged children aged 3 to 8 who were referred for antisocial behavior were randomly assigned to receive parent training or to be in a control group. The parent training program, based on videotapes, covered praise and rewards, setting limits, and handling misbehavior. Follow-up parent interviews and observations showed that the antisocial behavior of the experimental children decreased significantly compared to that of the controls. Furthermore, after the intervention, experimental parents gave their children more praise to encourage desirable behavior and used more effective commands to obtain compliance. Sanders and his colleagues (Sanders, Markie-Dadds, Tully, & Bor, 2000) in Brisbane, Australia, developed the Triple-P Parenting program. This program either can be delivered to the whole community in primary prevention using the mass media or can be used in secondary prevention with high-risk or clinic samples. Sanders et al. evaluated the success of Triple-P with high-risk children aged 3 by randomly assigning them either to receive Triple-P or to be in a control group. The Triple-P program involves teaching parents 17 child management strategies, including talking with children, giving physical affection, praising, giving attention, setting a good example, setting rules, giving clear instructions, and using appropriate penalties for misbehavior (a “time-out,” or sending the child to his or her room). The evaluation showed that the Triple-P program was successful in reducing children’s antisocial behavior.
C. Other Parenting Interventions
Another parenting intervention, termed functional family therapy, was developed by Alexander in Utah (see Sexton &Alexander, 2000). This aimed to modify patterns of family interaction by modeling, prompting, and reinforcement; to encourage clear communication of requests and solutions between family members; and to minimize conflict. Essentially, all family members were trained to negotiate effectively, to set clear rules about privileges and responsibilities, and to use techniques of reciprocal reinforcement with each other. The program was evaluated by randomly assigning 86 delinquent youths to experimental or control conditions. The results showed that this technique halved the recidivism rate of minor delinquents in comparison with other approaches (client-centered or psychodynamic therapy). Its effectiveness with more serious offenders was confirmed in a replication study using matched groups. Chamberlain (1998) in Oregon evaluated treatment foster care (TFC), which was used as an alternative to custody for delinquent youths. Custodial sentences for delinquents were thought to have undesirable effects, especially because of the bad influence of delinquent peers. In treatment foster care, families in the community were recruited and trained to provide a placement for delinquent youths. The TFC youths were closely supervised at home, in the community, and in the school, and their contacts with delinquent peers were minimized. The foster parents provided a structured daily living environment with clear rules and limits, consistent discipline for rule violations, and one-to-one monitoring. The youths were encouraged to develop academic skills and desirable work habits. In the evaluation, 79 chronic male delinquents were randomly assigned to treatment foster care or to regular group homes where they lived with other delinquent youths. A 1-year follow-up showed that the TFC boys had fewer criminal referrals and lower self-reported delinquency. Hence, this program seemed to be an effective treatment for delinquency.
D. Multisystemic Therapy
Multisystemic therapy (MST) is an important multiple-component family preservation program that was developed by Henggeler and his colleagues (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) in South Carolina. The particular type of treatment is chosen according to the particular needs of the youth. Therefore, the nature of the treatment is different for each person. MST is delivered in the youth’s home, school, and community settings. The treatment typically includes family intervention to promote the parent’s ability to monitor and discipline the adolescent, peer intervention to encourage the choice of prosocial friends, and school intervention to enhance competence and school achievement. In an evaluation by Henggeler et al. (1998), 84 serious delinquents (with an average age of 15) were randomly assigned either to receive MST or the usual treatment (which mostly involved placing the juvenile in a setting outside the home). The results showed that the MST group had fewer arrests and fewer self-reported crimes in a 1-year follow-up. In another evaluation, in Missouri, Charles Borduin and his colleagues randomly assigned 176 juvenile offenders (with an average age of 14) either to MST or to individual therapy focusing on personal, family, and academic issues. Four years later, only 29% of the MST offenders had been rearrested, compared with 74% of the individual therapy group (cited in Aos et al., 2001).According to Steve Aos et al. (2001), MST had one of the highest cost-benefit ratios of any program. For every $1 spent on it, $13 were saved in victim and criminal justice costs. Unfortunately, disappointing results were obtained in a large-scale independent evaluation of MST in Ontario, Canada, by Alan Leschied and Alison Cunningham (1998). Over 400 youths who were either offenders or at risk of offending were randomly assigned to receive either MST or the usual services (typically probation supervision). Six months after treatment, 28% of the MST group had been reconvicted, compared with 31% of the control group, a nonsignificant difference. Therefore, it is unclear how effective MST is when it is implemented independently.
E. Is Family-Based Intervention Effective?
Evaluations of the effectiveness of family-based intervention programs have produced both encouraging and discouraging results. In order to assess effectiveness according to a large number of evaluations, Farrington and Welsh (2003) reviewed 40 evaluations of family-based programs, each involving at least 50 persons in experimental and control groups combined. All of these had outcome measures of delinquency or antisocial child behavior. Of the 19 studies with outcome measures of delinquency, 10 found significantly beneficial effects of the intervention and 9 found no significant effect. Happily, no study found a significantly harmful effect of family-based treatment. Over all 19 studies, the average effect size (d, the standardized mean difference) was .32. This was significantly greater than zero. When it was converted into the percentage reconvicted, a d value of .32 corresponded to a decrease in the percentage reconvicted from 50% to 34%. Therefore, it was concluded that, taking all 19 studies together, they showed that family-based intervention had substantial desirable effects. Also, there was evidence that some programs (e.g., home visiting) had financial benefits that greatly exceeded program costs. The next section reviews school-based prevention programs, most of which also had a family-based component. The Perry preschool program is reviewed first. This is perhaps the most influential early prevention project, because it concluded that $7 were saved for every $1 expended. Then the famous programs combining child skills training and parent training, implemented in Montreal by Richard Tremblay and in Seattle by David Hawkins, are reviewed, and also anti-bullying programs by Dan Olweus in Norway and Peter Smith in England.