Prevention and intervention

There are four major types of prevention which relate to the reduction of serious antisocial behaviour and juvenile offending. (84,>

1. Criminal justice prevention—deterrence, incapacitation, and rehabilitation strategies operated by law enforcement and criminal justice agencies.

2. Situational prevention—designed to reduce the opportunities for antisocial behaviour and to increase the risk and difficulty of committing antisocial acts.

3. Community prevention—interventions designed to change the social conditions and social institutions that influence antisocial behaviour in communities.

4. Developmental prevention—interventions designed to inhibit the development of antisocial behaviour in individuals by targeting risk and protective factors that influence human development.

Successful early preventative interventions for juvenile offending and related antisocial behaviour depend on the efficacy of parent training, and preschool programmes that enable young children to understand more readily the consequences of their behaviour for self and peers, critically helping them to make safe choices and reach safe autonomy in adolescence. Lipsey, (85> in a review of outcome studies of education and psychotherapeutic intervention, and Kazdin,(86) in a major review of the effectiveness of psychotherapy in reducing problem behaviour in young people, suggest the importance of three strategies:

• primary population-based preventative intervention

• secondary interventions focused on high-risk groups

• programmes centred on tertiary treatment.

Early prevention (birth to 4 years)

Problems in pregnancy and infancy can be alleviated by home-visiting programmes designed to help mothers. (8J) Not only has this been found to lead to teenage mothers having heavier babies and fewer preterm deliveries, but postnatal home visits caused a decrease in recorded child physical abuse and neglect in the first 2 years of life. The last result is important because of the finding that being physically abused or neglected as a child predicts later violent antisocial behaviour. (88)

One of the most successful prevention programmes has been the Perry preschool project targeted at disadvantaged African-American children. The children (aged 3-4 years) attended a daily prescribed programme backed up by weekly home visits. Seven other Headstart projects followed. (89> Gains in intellectual benefits were short lived, but at follow-up some children now in their late twenties who had experienced the programmes had decreased school failure and decreased antisocial behaviour, and were more likely to be employed.

Childhood intervention

Whatever the treatment model, safe interventions have to be based on an assessment that has established a global picture of the child or young person, including health needs and risk factors. This should include the situations in which the behaviour occurs, specific triggers, and quantification of the behaviour. Cognitive and emotional assessment has to examine perceptions, thoughts, and feelings associated with the behaviour. Interventions have to be applied with continuous monitoring and evaluation of treatment outcome on all aspects of the young person's life.

Psychological interventions

Social skills training enhances abilities in positive social interaction. Behaviourally based tools include instructions, modelling, role-playing, coaching, and feedback for children and young people who have previously dealt with new social encounters through antisocial behaviour. (90)

Self-instructional training is designed to modify the things that children say to themselves and the autonomic cognitive events that play a regulatory role in everyday behaviour. Interventions containing cognitive elements have better outcomes than those which do not. (91>

In social problem-solving an attempt is made to foster interpersonal problem-solving skills in order to lead to conflict avoidance and hence reduce the risk of aggressive antisocial behaviour.(92)

Anger control training is a widely used form of cognitive- behavioural work, combining self-instructional methods with relaxation training into a model of stress inoculation. Encouraging results have been reported with aggressive adolescent inpatients with severe behaviour disorders. (93>

Increasingly, combined multimodel treatment programmes have been employed. The most complex approach to reduction of violent behaviour in young people is aggression replacement training, formulated to meet the growing problem of juvenile gang violence in the United States. (94) This approach brings together social skills training, self-instructional and anger control training, and moral reasoning enhancement, and is carried out in community- and institutional-based settings.

Family-based interventions

The possibility of training parents in improved child-management skills emerged in the 1970s. The most extensive work in this area has been undertaken in Oregon.(95> The social learning theory underpinning parent training was confirmed in practice by observational studies carried out at the Oregon Social Learning Centre. They highlighted three key mechanisms by which some parents maintained undesirable behaviour in their children.

1. The positive reinforcement of undesirable behaviour by a response of angry or irritable attention. For a child otherwise starved of pleasant attention, unpleasant consequences may be reinforcing.

2. Desirable behaviour was extinguished by lack of attention and did not enable a child to obtain what he or she wanted.

3. Negative reinforcement, such as the removal of an unpleasant stimulus (negative referring to the absence of something acting as a reinforcer), is likely to continue the behaviours.

Sessions take place 'live' in the presence of the child, and techniques are repeatedly practised so that the parent actually experiences handling the child differently.

Webster-Stratton(96) developed a model of group treatment, enabling parents of about eight children to receive tuition in parenting techniques at the same time. Parent training is most likely to succeed where the essential nature of play is explored, parents and children are praised, role play is used, and the parents' own childhood is explored. Components that can be added to parent training therapy include home visits, encouraging telephone calls, systemic family therapy (e.g. incorporating attachment theory into a principally structural model ^i), additional therapy for parents, and practical assistance (liaising with social services). Children may need individual psychodynamic therapy, especially those who have experienced abuse, group therapy to encourage the child to recognize feelings, and specific behaviour modification. Liaison with school is essential as teachers may become an important part of therapy, incorporating components of the child's treatment in the classroom. Training for teachers may well benefit other children in the class, (98) and in some cases, where change between parent and child has proved not possible, there may be recommendations about schooling within a therapeutic environment available in schools for children with emotional and behavioural disturbance. (99) Any intervention should be preceded by a thorough assessment which detects comorbid conditions. Child mental health clinics throughout the United Kingdom are now developing parent training. (1°0)

School and community prevention Peer programmes

The influence of peers and the community becomes increasingly important for adolescents. Thus intervention strategies geared towards resistance of peer influence, classroom management, antibullying initiatives in school, and utilization of multiple-component programmes across home and school are likely to have more impact.

The most famous antibullying programme, aiming to increase awareness and knowledge of teachers, parents, and children about bullying and to dispel the myths surrounding it, was implemented by Olweus(l01) in Norway. A similar programme was implemented in the United Kingdom by Smith and SharpA02)

Hawkins et al.^.H3) carried out important school-based prevention programmes in Seattle that combined parent training, teacher training, and skills training. Evaluation after 18 months showed that boys who received the programmes were significantly less aggressive than controls, and that girls, although no less aggressive, were less depressed. At the age of 10 these children were less likely to have initiated delinquency and alcohol use.

Communities that Care(l04) is a risk-focused prevention programme tailored to the needs of each community, and targets four main behaviours that are damaging to the lives of adolescents and the communities where they live: youth crime, drug abuse, school-age pregnancy and sexually transmitted diseases, and school failure. Key community leaders (the mayor, headteachers, the police chief, and business leaders) are brought together to agree on the goals of a programme for their particular city, town, district, or public housing estate. The key leaders set up a Community Board that is accountable to them and has representatives from the four jurisdictions of health education care and justice together with parents, youth groups, churches, business, and media. The Board carries out a risk assessment and develops a prevention plan from a menu of strategies tapping into professional help and assistance, including child mental health teams.

Communities that Care is now established in the United Kingdom modelled on the American programmes and on other British preventative public health campaigns/!05)

Problems with prevention and intervention programmes

• Outcomes are related to delinquency and adult crime more than to antisocial behaviour per se.

• Preventions and intervention programmes are geared to the full variation of antisocial behaviour rather than to serious antisocial behaviour.

• Programmes are still largely directed towards males.

• Programmes use techniques that are primarily risk focused rather than taking a holistic approach, addressing quality of life, assessment of particular health needs, and meeting current needs.

• The overall approaches are those of tackling social and psychological aspects of crime, which do not always encompass individual development and psychopathology. The process of personality development in adolescence remains poorly understood.

• There remains a need for specialist treatment and care for the group exhibiting serious antisocial behaviour.

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