Prevention 315correspond closely with the ways in which mental disorders typically lead
to impairment. For example, this may be by interfering with the ability to
be productive(indexed, for example, by successful school work, successfully
taking part in constructive pastimes and sporting activities, the capacity
to take part appropriately and helpfully in everyday household activities,
such as shared mealtimes, trips out of the house, and so on). Secondly,
mental disorders may impair the ability tomaintain good relationshipswith
parents, siblings, peers and other adults such as teachers (indexed, for
example, by successfully doing joint activities, good communication and
emotional support). There are well validated measures of psychosocial
functioning, but they are not generally recognised to be equivalent to
quality of life measures.
The example of conduct disorder
Conduct disorder illustrates what might be achieved in preventive child
psychiatry. It meets the four criteria for feasibility:
1 It is relatively easy to screen for risk, for example, short questionnaires
of antisocial behaviour symptoms can be filled in by teachers and
parents. A high score predicts future conduct disorder well, especially
if combined with other factors such as hyperactivity and poor peer
relationships, which are also covered by some screening questionnaires.
2 There are effective interventions (see discussion below).
3 There are serious and expensive consequences if the condition develops.
Early-onset conduct disorder has lifelong consequences, including a
markedly increased risk for frequent offending, drug addiction, low
scholastic attainment, unemployment, disrupted relationships, violent
injury and premature death. One community-based ‘cost of illness’
study found that by age 28, individuals who had had conduct disorder
in childhood cost society ten times as much as controls.
4 Treatment for established disorders is expensive and typically only partly
successful. While in adolescence comprehensive treatment programmes
such as multisystemic therapy have been shown to reduce offending
by 20–50% in demonstration projects in the USA, it is very expensive
to deliver (around£20,000–£30,000 per case), and in most countries,
including the UK, there is little capacity to deliver it.
Literally hundreds of randomised controlled trials have shown the ef-
fectiveness of parent training, withclinically referredchildren with conduct
symptoms. Recently, a number of large randomised controlled trials have
examined the effectiveness of targeted prevention programmes based on
improving multiple factors inat riskchildren drawn from the general
population. The Families and Schools Together project (FASTrack) took
1,000 5-year-olds who were above the 90th percentile for antisocial
behaviour. Over a whole school year, half were randomised to receive the