Understanding risk involves judgment and balance. To manage risks, social workers and other practitioners should make decisions with the best interests of the child in mind, informed by the evidence available and underpinned by knowledge of child development. A desire to think the best of adults and to hope they can overcome their difficulties should not subvert the need to protect children from chaotic, abusive and neglectful homes.
Social workers and practice supervisors should always reflect the latest research on the impact of abuse and neglect and relevant findings from serious case and practice reviews when analysing the level of need and risk faced by the child. This should be reflected in the case recording. Assessment is a dynamic and continuous process that should build upon the history of every individual case, responding to the impact of any previous services and analysing what further action might be needed.
Social workers should build on this with help from other practitioners from the moment that a need is identified.
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A social worker may arrive at a judgment early in the case but this may need to be revised as the case progresses and further information comes to light. It is a characteristic of skilled practice that social workers revisit their assumptions in the light of new evidence and take action to revise their decisions in the best interests of the individual child. Decision points and review points involving the child and family and relevant practitioners should be used to keep the assessment on track. This is to ensure that help is given in a timely and appropriate way and that the impact of this help is analysed and evaluated in terms of the improved outcomes and welfare of the child.
Every assessment should be focused on outcomes, deciding which services and support to provide to deliver improved welfare for the child. The plan should set out what services are to be delivered, and what actions are to be undertaken, by whom and for what purpose. The plan should reflect this and set clear measurable outcomes for the child and expectations for the parents, with measurable, reviewable actions for them. This will be important for neglect cases where parents and carers can make small improvements.
The test should be whether any improvements in adult behaviour are sufficient and sustained. Social workers should consider the need for further action and record their decisions. The review points should be agreed by the social worker with other practitioners and with the child and family to continue evaluating the impact of any change on the welfare of the child.
Supervision should support practitioners to reflect critically on the impact of their decisions on the child and their family. The social worker should review the plan for the child.
Chapter 1: Assessing need and providing help
They should ask whether the help given is leading to a significant positive change for the child and whether the pace of that change is appropriate for the child. Practitioners working with children should always have access to colleagues to talk through their concerns and judgments affecting the welfare of the child. Assessment should remain an ongoing process, with the impact of services informing future decisions about action. Known transition points for the child should be planned for in advance.
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This includes where children are likely to transition between child and adult services. The timeliness of an assessment is a critical element of the quality of that assessment and the outcomes for the child. This will require judgments to be made by the social worker on each individual case. Adult assessments, for example, parent carer or non-parent carer assessments, should also be carried out in a timely manner, consistent with the needs of the child. The social worker should clarify with the referrer, when known, the nature of the concerns and how and why they have arisen.
Within one working day of a referral being received, a local authority social worker should acknowledge receipt to the referrer and make a decision about next steps and the type of response required. This will include determining whether:. The child and family must be informed of the action to be taken, unless a decision is taken on the basis that this may jeopardise a police investigation or place the child at risk of significant harm.
The maximum timeframe for the assessment to conclude, such that it is possible to reach a decision on next steps, should be no longer than 45 working days from the point of referral. If, in discussion with a child and their family and other practitioners, an assessment exceeds 45 working days, the social worker should record the reasons for exceeding the time limit. Whatever the timescale for assessment, where particular needs are identified at any stage of the assessment, social workers should not wait until the assessment reaches a conclusion before commissioning services to support the child and their family.
In some cases, the needs of the child will mean that a quick assessment will be required. It is the responsibility of the social worker to make clear to children and families how the assessment will be carried out and when they can expect a decision on next steps. Local authorities should determine their local assessment processes through a local protocol.
The following descriptors and flow charts set out the steps that practitioners should take when working together to assess and provide services for children who may be in need, including those suffering harm. The flow charts cover:. Where there is a risk to the life of a child or a likelihood of serious immediate harm, local authority social workers, the police or NSPCC should use their statutory child protection powers to act immediately to secure the safety of the child.
Police powers to remove a child in an emergency should be used only in exceptional circumstances where there is insufficient time to seek an EPO or for reasons relating to the immediate safety of the child. An EPO , made by the court, gives authority to remove a child and places them under the protection of the applicant. When considering whether emergency action is necessary, an agency should always consider the needs of other children in the same household or in the household of an alleged perpetrator. The local authority in whose area a child is found in circumstances that require emergency action the first authority is responsible for taking emergency action.
If the child is looked-after by, or the subject of a child protection plan in another authority, the first authority must consult the authority responsible for the child. Only when the second local authority explicitly accepts responsibility to be followed up in writing is the first authority relieved of its responsibility to take emergency action. Planned emergency action will normally take place following an immediate strategy discussion.
For further guidance on EPOs see Chapter 4 of the statutory guidance document for local authorities , Court orders and pre-proceedings DfE, April Assessments should be carried out in a timely manner reflecting the needs of the individual child, as set out in this chapter. The plan should set clear measurable outcomes for the child and expectations for the parents. The plan should reflect the positive aspects of the family situation as well as the weaknesses. Where a child in need has moved permanently to another local authority area, the original authority should ensure that all relevant information including the child in need plan is shared with the receiving local authority as soon as possible.
Support should continue to be provided by the original local authority in the intervening period. The receiving authority should work with the original authority to ensure that any changes to the services and support provided are managed carefully.
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Where a child in need is approaching 18 years of age, this transition point should be planned for in advance. Where information gathered during an assessment which may be very brief results in the social worker suspecting that the child is suffering or likely to suffer significant harm, the local authority should hold a strategy discussion to enable it to decide, with other agencies, whether it must initiate enquiries under section 47 of the Children Act Assessments should determine whether the child is in need, the nature of any services required and whether any specialist assessments should be undertaken to assist the local authority in its decision-making.
This might take the form of a multi-agency meeting or phone calls and more than one discussion may be necessary. A strategy discussion can take place following a referral or at any other time, including during the assessment process and when new information is received on an already open case. A local authority social worker, health practitioners and a police representative should, as a minimum, be involved in the strategy discussion. Other relevant practitioners will depend on the nature of the individual case but may include:. All attendees should be sufficiently senior to make decisions on behalf of their organisation and agencies.
Where there are grounds to initiate an enquiry under section 47 of the Children Act , decisions should be made as to:. The principles and parameters for the assessment of children in need at chapter 1 paragraph 40 should be followed for assessments undertaken under section 47 of the Children Act A section 47 enquiry is carried out by undertaking or continuing with an assessment in accordance with the guidance set out in this chapter and following the principles and parameters of a good assessment.
Local authority social workers should lead assessments under Section 47 of the Children Act The police, health practitioners, teachers and school staff and other relevant practitioners should help the local authority in undertaking its enquiries. A section 47 enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of or likely to be suffering significant harm.
Guidance on interviewing victims and witnesses, and guidance on using special measures Local authority social workers are responsible for deciding what action to take and how to proceed following section 47 enquiries. As a last resort, the safeguarding partners should have in place a quick and straightforward means of resolving differences of opinion.
To bring together and analyse, in an inter-agency setting, all relevant information and plan how best to safeguard and promote the welfare of the child. It is the responsibility of the conference to make recommendations on how organisations and agencies work together to safeguard the child in future. To review whether the child is continuing to suffer or is likely to suffer significant harm, and review developmental progress against child protection plan outcomes.
Where the decision to return a child to the care of their family is planned, the local authority should undertake an assessment while the child is looked-after — as part of the care planning process under regulation 39 of the Care Planning Regulations See The Children Act guidance and regulations, Volume 2: This assessment should consider what services and support the child and their family might need. The decision to cease to look after a child will, in most cases, require approval under regulation 39 of the Care Planning Regulations Where a child who is accommodated under section 20 returns home in an unplanned way, for example, the decision is not made as part of the care planning process but the parent removes the child or the child decides to leave, the local authority must consider whether there are any immediate concerns about the safety and wellbeing of the child.
There should be a clear plan for all children who return home that reflects current and previous assessments, focuses on outcomes and includes details of services and support required. Action to be taken following reunification:. We do this through our unique blend of legal, practice and technical expertise and by continuously learning from our wide range of customers across the social care sectors.
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Assessing need and providing help Contents Early help Identifying children and families who would benefit from early help Effective assessment of the need for early help Provision of effective early help services Accessing help and services Referral Information sharing Statutory requirements for children in need Assessment of disabled children and their carers Assessment of young carers Assessment of children in secure youth establishments Contextual safeguarding Purpose of assessment Local protocols for assessment The principles and parameters of a good assessment Focusing on the needs and views of the child Developing a clear analysis Focusing on outcomes Timeliness Processes for managing individual cases Flow chart 1: Action taken when a child is referred to local authority children's social care services Flow chart 2: Immediate protection Flow chart 3: Action taken for an assessment of a child under the Children Act Flow chart 4: Action following a strategy discussion Flow chart 5: What happens after the child protection conference, including the review?
Children returning home from care to their families Early help 1. Effective early help relies upon local organisations and agencies working together to: Identify children and families who would benefit from early help; Undertake an assessment of the need for early help; Provide targeted early help services to address the assessed needs of a child and their family which focuses on activity to improve the outcomes for the child. Identifying children and families who would benefit from early help 4. Practitioners should, in particular, be alert to the potential need for early help for a child who: Effective assessment of the need for early help 7.
For an early help assessment to be effective: It should be undertaken with the agreement of the child and their parents or carers, involving the child and family as well as all the practitioners who are working with them. Provision of effective early help services Accessing help and services Section 17 of the Children Act children in need ; Section 47 of the Children Act reasonable cause to suspect a child is suffering or likely to suffer significant harm ; Section 31 of the Children Act care and supervision orders ; Section 20 of the Children Act duty to accommodate a child.
Clear procedures and processes for cases relating to: The abuse, neglect and exploitation of children; Children managed within the youth secure estate; Disabled children. To ensure effective safeguarding arrangements: All organisations and agencies should have arrangements in place that set out clearly the processes and the principles for sharing information. All practitioners should be particularly alert to the importance of sharing information when a child moves from one local authority into another, due to the risk that knowledge pertinent to keeping a child safe could be lost; All practitioners should aim to gain consent to share information, but should be mindful of situations where to do so would place a child at increased risk of harm.
Information may be shared without consent if a practitioner has reason to believe that there is good reason to do so, and that the sharing of information will enhance the safeguarding of a child in a timely manner. When decisions are made to share or withhold information, practitioners should record who has been given the information and why.
To share information effectively: This includes allowing practitioners to share information without consent, if it is not possible to gain consent, it cannot be reasonably expected that a practitioner gains consent, or if to gain consent would place a child at risk. Myth-busting guide to information sharing Sharing information enables practitioners and agencies to identify and provide appropriate services that safeguard and promote the welfare of children.
Data protection legislation is a barrier to sharing information No — the Data Protection Act and GDPR do not prohibit the collection and sharing of personal information, but rather provide a framework to ensure that personal information is shared appropriately. Consent is always needed to share personal information No — you do not necessarily need consent to share personal information. The common law duty of confidence and the Human Rights Act prevent the sharing of personal information No — this is not the case.
Where possible, children should be seen alone; A child in need is defined under the Children Act as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Children in need may be assessed under section 17 of the Children Act by a social worker; Some children in need may require accommodation because there is no one who has parental responsibility for them, because they are lost or abandoned, or because the person who has been caring for them is prevented from providing them with suitable accommodation or care.
Such enquiries, supported by other organisations and agencies, as appropriate, should be initiated where there are concerns about all forms of abuse, neglect. This includes Female Genital Mutilation and other Honour-Based Violence , and extra-familial threats including radicalisation and sexual or criminal exploitation; There may be a need for immediate protection whilst an assessment or enquiries are carried out.
Assessment of disabled children and their carers Assessment of young carers Assessment of children in secure youth establishments Purpose of assessment Whatever legislation the child is assessed under, the purpose of the assessment is always: Local protocols for assessment The principles and parameters of a good assessment It investigates three domains: Focusing on the needs and views of the child Developing a clear analysis Critical reflection through supervision should strengthen the analysis in each assessment. Focusing on outcomes This will include determining whether: The child requires immediate protection and urgent action is required; The child is in need and should be assessed under section 17 of the Children Act ; There is reasonable cause to suspect that the child is suffering or likely to suffer significant harm, and whether enquires must be made and the child assessed under section 47 of the Children Act ; Any services are required by the child and family and what type of services; Further specialist assessments are required to help the local authority to decide what further action to take; To see the child as soon as possible if the decision is taken that the referral requires further assessment.
Processes for managing individual cases The flow charts cover: Action taken when a child is referred to local authority children's social care services Immediate Protection Where there is a risk to the life of a child or a likelihood of serious immediate harm, local authority social workers, the police or NSPCC should use their statutory child protection powers to act immediately to secure the safety of the child.
Multi-agency working Planned emergency action will normally take place following an immediate strategy discussion. Initiate a strategy discussion to discuss planned emergency action. Where a single agency has to act immediately, a strategy discussion should take place as soon as possible after action has been taken; See the child this should be done by a practitioner from the agency taking the emergency action to decide how best to protect them and whether to seek an EPO; Wherever possible, obtain legal advice before initiating legal action, in particular when an EPO is being sought.
Initial discussions with the child should be conducted in a way that minimises distress to them and maximises the likelihood that they will provide accurate and complete information, avoiding leading or suggestive questions; Record the assessment findings and decisions and next steps following the assessment; Inform, in writing, all the relevant agencies and the family of their decisions and, if the child is a child in need, of the plan for providing support; Inform the referrer of what action has been or will be taken. All involved practitioners should: Other relevant practitioners will depend on the nature of the individual case but may include: The discussion should be used to: Share available information; Agree the conduct and timing of any criminal investigation; Decide whether enquiries under section 47 of the Children Act must be undertaken.
Where there are grounds to initiate an enquiry under section 47 of the Children Act , decisions should be made as to: What further information is needed if an assessment is already underway and how it will be obtained and recorded; What immediate and short term action is required to support the child, and who will do what by when; Whether legal action is required. Convene the strategy discussion and make sure it: Action following a strategy discussion Initiating section 47 enquiries A section 47 enquiry is carried out by undertaking or continuing with an assessment in accordance with the guidance set out in this chapter and following the principles and parameters of a good assessment.
Purpose A section 47 enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of or likely to be suffering significant harm. Provide any of a range of specialist assessments. In general, the findings with children have not been consistent. For example, in the Pittsburgh Youth cohort, boys with long-standing conduct problems showed downward changes in urinary adrenaline level following a stressful challenge task, whereas prosocial boys showed upward responses McBurnett et al.
However other studies have failed to find an association between conduct disorder and measures of noradrenaline in children Hill, It should be borne in mind that neurotransmitters in the brain are only indirectly measured, that most measures of neurotransmitter levels are crude indicators of activity and that little is known about neurotransmitters in the juvenile brain. The association holds after controlling for potential confounds such as race, socioeconomic status, academic attainment and test motivation.
Executive functions are the abilities implicated in successfully achieving goals through appropriate and effective actions. Specific skills include learning and applying contingency rules, abstract reasoning, problem solving, self-monitoring, sustained attention and concentration, relating previous actions to future goals, and inhibiting inappropriate responses. These mental functions are largely, although not exclusively, associated with the frontal lobes.
Also, a slow skin-conductance response to aversive stimuli is found Fung et al. Dodge Dodge, proposed a model for the development of antisocial behaviours in social interactions. Several studies have supported these processes Dodge, There is an association between severe disadvantage and antisocial behaviour in children. The association between disadvantage and childhood antisocial behaviour is indirect, mediated via family relationships such as interparental discord and parenting quality, which is discussed below.
Parenting styles related to antisocial behaviour were described by Patterson in his major work Coercive Family Process Patterson, Conduct problems are associated with hostile, critical, punitive and coercive parenting. Of course, other explanations need to be considered: The E-Risk longitudinal twin study of British families Trzesniewski et al. The strong contribution of harsh, inconsistent parenting with lack of warmth to the causation of conduct problems provides an opportunity for intervention.
As evidence presented in this guideline will show, parenting programmes that reverse less optimal patterns of parenting and promote positive encouragement of children with the setting of clear boundaries that are calmly enforced lead to improvement of conduct problems. The quality of the parent—child relationship is crucial to later social behaviour, and if the child does not have the opportunity to make attachments, for example due to being taken into institutional care, this typically leads to subsequent problems in relating: One study found that ambivalent and controlling attachment predicted externalising behaviours after controlling for baseline externalising problems; disorganised child attachment patterns seem to be especially associated with conduct problems.
Although it seems obvious that poor parent—child relations in general predict conduct problems, it has yet to be established whether attachment difficulties as measured by observational paradigms have an independent causal role in the development of behaviour problems; attachment classifications could be markers for other relevant family risks.
However, in adolescence there is evidence that attachment representations independently predict conduct symptoms over and above parenting quality Scott et al. Several researchers have found that children exposed to domestic violence between adults are subsequently more likely to themselves become antisocial. Thus, a child may respond to fear arising from marital conflict by controlling their reactions through denial of the situation. This in turn may lead to inaccurate appraisal of other social situations and ineffective problem solving. Through parental fights, children may learn that aggression is a normal part of family relationships, that it is an effective way of controlling others and that aggression is sanctioned not punished.
Many parents use physical punishment, and parents of children with antisocial behaviour frequently resort to it out of desperation. Overall, associations between physical abuse and conduct problems are well established. In the Christchurch longitudinal study, child sexual abuse predicted conduct problems after controlling for other childhood adversities Fergusson et al. However, sometimes some parents resort to severe and repeated beatings that are clearly abusive. This typically terrifies the child, causes great pain and overwhelms the ability of the child to stay calm.
It leads the children to be less able to regulate their anger and teaches them a violent way of responding to stress. Unsurprisingly, elevated rates of conduct disorder result Jaffee et al. It has been difficult to establish any direct link between neighbourhood characteristics and antisocial child behaviour. Thus, neighbourhood characteristics were seen in overly simple ways, such as percentage of ethnic minority residents or percentage of lone-parent households.
Children and young people with antisocial behaviour have poorer peer relationships and associate with other children with similar antisocial behaviours. They have more aggressive and unhappy interactions with other children and they experience more rejection by children without conduct disorders Coie, The evidence above shows many associations between antisocial behaviour and a wide range of risk factors. The exact role in causation of most of these risk factors is unknown: Establishing a causal role for a risk factor is by no means straightforward, particularly as it is unethical to experimentally expose healthy children to risk factors to observe whether those factors can generate new conduct problems.
The use of genetically sensitive designs and the study of within-individual change in natural experiments and treatment studies have considerable methodological advantages for suggesting causal influences on conduct problems. Of those with early onset conduct disorder before the age of 8 years , about half have serious problems that persist into adulthood.
Many of the factors that predict poor outcome are associated with early onset see Table 1. To detect protective factors, children who do well despite adverse risk factors have been studied. Protective factors are mostly the opposite end of the spectrum of the same risk factor, thus good parenting and high IQ are protective.
Nonetheless, there are factors associated with resilience that are independent of known adverse influences. These include a good relationship with at least one adult who does not necessarily have to be the parent , a sense of pride and self-esteem, and skills or competencies.
Studies of groups of children with early-onset conduct disorder indicate a wide range of problems that are not only confined to antisocial acts as shown in Table 2. What is clear is that there are not only substantially increased rates of antisocial acts but also that the general psychosocial functioning of adults who had conduct disorder is strikingly poor. For most of the characteristics shown in Table 2 , the increase compared with controls is three- to ten-fold Fergusson et al.
Thus conduct disorder has widespread ramifications in most of the important domains of life, affecting work and relationships. The strength of the effects emphasises the extensive benefits that can accrue from successful treatment, and the importance of making this available to affected children and young people.
Different sets of influences impinge as the individual grows up and shape the life course. Many of these can accentuate problems. Thus a toddler with an irritable temperament and short attention span may not learn good social skills if they are raised in a family lacking them, and where the child can only get their way by behaving antisocially and grasping for what they need. At school they may fall in with a deviant crowd of peers, where violence and other antisocial acts are talked up and give them a sense of esteem.
They may then leave school with no qualifications and fail to find a job, and resort to drugs. To fund their drug habit they may resort to crime and, once convicted, find it even harder to get a job. Consequently, the number of adverse life events experienced is greatly increased Champion et al. The path from early hyperactivity into later conduct disorder is also not inevitable. In the presence of a warm supportive family atmosphere conduct disorders are far less likely than if the parents are highly critical and hostile. Other influences can, however, steer the individual away from and antisocial path.
The evidence for the effectiveness of treatments is the subject of the analyses in ensuing chapters.
Singly or in combination, they address parenting skills, family functioning, child interpersonal skills, difficulties at school, peer group influences and medication for coexistent hyperactivity. Parent training aims to improve parenting skills Scott, As the following chapters show, there are scores of randomised controlled trials RCTs suggesting that it is effective for children up to about 10 years old.
Parenting interventions based on social learning theory address the parenting practices that were identified in research as contributing to conduct problems. Typically, they include five elements:. Alternatively, group treatments with parents alone have been shown to be equally effective. Trials show that parent management training is effective in reducing child antisocial behaviour in the short term for half to two-thirds of families, with little loss of effect at 1- to 3-year follow-up. Functional family therapy, multisystemic therapy and multidimensional treatment foster care MTFC aim to change a range of difficulties which impede effective functioning of young people with conduct disorder.
These programmes use a combination of social learning theory, cognitive and systemic family therapy interventions. Functional family therapy addresses family processes, including high levels of negativity and blame, and characteristically seeks to improve communication between parent and young person, reduce interparental inconsistency, tighten up on supervision and monitoring, and negotiate rules and the sanctions to be applied for breaking them.
Most other varieties of family therapy have not been subjected to controlled trials for young people with conduct disorder or delinquency so cannot be evaluated for their efficacy. Functional family therapy is an assertive outreach model and sessions typically take place in the family home. There is a manual for the therapeutic approach and adherence is checked weekly by the supervisor. Following the assessment, proven methods of intervention are used to address difficulties and promote strengths.
As for functional family therapy, treatment is delivered in the situation where the young person lives. Second, the therapist has a low caseload four to six families and the team is available 24 hours a day. Fourth, regular written feedback on progress towards goals from multiple sources is gathered by the therapist and acted upon.
Fifth, there is a manual for the therapeutic approach and adherence is checked weekly by the supervisor. MTFC is another intervention which has been shown to improve the quality of encouragement and supervision that young people with conduct disorder receive. The young person temporarily lives with foster carers who are specially trained and, in addition, receives help from individual therapists at school and in the community.
Most of the programmes to improve child interpersonal skills derive from cognitive behavioural therapy CBT. What the programmes have in common is that the young people are trained to:. Over the longer term, the programmes aim to increase positive social behaviour by teaching the young person to:. These can be divided into learning problems and disruptive behaviour. There are proven programmes to deal with specific learning problems, such as specific reading difficulties, including Reading Recovery 1.
However, few of the programmes have been specifically evaluated for their ability to improve outcomes in children with conduct disorder, although at the time of writing trials are in progress. Some of these schemes specifically target children with conduct problems. A few interventions have aimed to reduce the bad influence of deviant peers. A number attempted this through group work with other conduct disordered youths, but outcome studies showed a worsening of antisocial behaviour. Current treatments therefore either see youths individually and try to steer them away from deviant peers, or work in small groups of around three to five youths where the therapist can control the content of sessions.
Some interventions place youths with conduct disorder in groups with well-functioning youths. Where there is comorbid hyperactivity in addition to conduct disorder, several studies attest to a large reduction in both overt and covert antisocial behaviour with the use of medication, both at home and at school NCCMH, Medication for pure conduct disorders is less well-established and is reviewed in this guideline. Practical measures such as assisting with transport, providing childcare, and holding sessions in the evening or at other times to suit the family will all help.
Many of the parents of children with conduct disorder may themselves have difficulty with authority and officialdom, and be very sensitive to criticism. Therefore, the approach is more likely to succeed if it is respectful of their point of view, does not offer overly prescriptive solutions and does not directly criticise parenting style. Practical homework tasks increase changes, as do problem-solving telephone calls from the therapist between sessions.
Parenting interventions may need to go beyond skill development to address more distal factors which prevent change. For example, drug or alcohol abuse in either parent, maternal depression and a violent relationship with the partner are all common. Assistance in claiming welfare and benefits and help with financial planning may reduce stress from debts. A multimodal approach is likely to see greater changes. Therefore, involving the school or the local education authority in treatment by visiting and offering strategies for managing the child in class is usually helpful, as is advocating for extra tuition where necessary.
If the school seems unable to cope despite extra resources, consideration could be given to moving the child to a unit that specialises in the management of behavioural difficulties, where skilled staff may be able to improve child functioning so a later return to mainstream school may be possible. Avoiding antisocial peers and building self-esteem may be helped by the child attending after-school clubs and holiday activities.
Where parents are not coping or a damaging abusive relationship is detected, it may be necessary to liaise with the social services department to arrange respite for the parents or a period of foster care. It is important during this time to work with the family to increase their skills so that the child can return to the family. Where there is permanent breakdown, long-term fostering or adoption may be recommended. Conduct disorder should offer good opportunities for prevention because it can be detected early reasonably well, early intervention is more effective than later and there are a number of effective interventions.
In the US a number of comprehensive interventions have been tested. They were then offered intervention which was given for 1 year in the first instance and comprised:. However, outcomes have been modest. In the UK, there has been a drive to disseminate parenting programmes widely Scott, Although a review of universal prevention interventions that is, those aimed at the general population is outside the scope of this guideline, a range of selective preventions that is, those aimed at individuals who are at high risk for developing the disorder or are showing very early signs or symptoms are reviewed.
The economic consequence of conduct disorder is characteristically huge, with considerable resource inputs from several government and private sectors. Though the condition can be considered primarily to be a mental health problem American Psychiatric Association, , the healthcare service provisions for conduct disorder and the resulting healthcare costs are rather small when compared with costs incurred by other sectors such as the criminal justice system Scott et al.
This is as a result of associated crime committed by the individuals, with resultant significant social costs and harm to individuals and their victims, families and carers, and to society at large Welsh et al. Overall, evidence for the cost estimates incurred due to conduct disorder varies widely and tends to be great when a societal perspective is taken.
The cost of conduct disorder, like other health problems, often includes both direct service costs and indirect costs, such as productivity loss as a result of health problems. The extent of direct costs is closely related to the quantity of services utilised by the individual.
In comparison with other common types of psychiatric disorders in children and adolescents, those with conduct disorder are more likely to be heavy users of social services than those with emotional disorders or hyperkinetic disorder, and they are also more likely to utilise primary healthcare and specialist education services than those with emotional disorders Shivram et al. Similarly, in an earlier work on service utilisation by this population Vostanis et al. Depending on the setting where service is delivered and the prevailing health condition of the individual for example a child or young person with conduct disorder, conduct problems, oppositional defiant disorder or if they are a juvenile offender , there is considerable variation in the total cost of the services incurred by people with conduct disorders.
Costs accumulated by individuals with conduct disorder are about ten times more than those with no conduct problem and three times that of the costs incurred by individuals with conduct problems. Similarly, in a US study comparing the costs of children with conduct disorder, oppositional defiant disorder, elevated levels of problem behaviour and those without any of these disorders Foster et al. Few of the cost studies included costs from all relevant sectors, such as health, education, social services, criminal justice, family and carer, and voluntary sectors, and some studies reported separate cost estimates for services provided to juvenile offenders who were already in contact with the criminal justice system.
Other than criminal justice system costs, costs to family and carers, where reported, are the second most significant costs of conduct disorder. There is little evidence on the annual mean cost of services for individuals who have conduct disorder in addition to other co-existing health problems. Service domains included in the estimate were health and the criminal justice system, and therefore greatly under-estimate the actual mean service costs for such individuals.
Another UK study Barrett et al. Services provided in secured accommodation were found to be around three times higher than those provided in the community. The cost of crime has huge policy implications in estimating the costs of conduct disorder. Because of the strong link between conduct disorder and probable criminal activities, the high cost of crime is often estimated to quantify the extent of the economic consequences of treating conduct disorder.
Methods of crime cost estimation and cost components differ greatly among studies. However, crime costs are generally estimated to include three basic cost categories: Often estimated are costs as a consequence of crime and costs in response to crime, such as tangible service costs and intangible costs for example pain, suffering or grief suffered by victims of crime Cohen, ; McCollister et al. Given the variation in the methods used in crime cost estimation and the cost components included in the estimate, the reported costs of crime are also associated with wide variations.
Notwithstanding the extensive literatures on crime costs, there are difficulties in accurately estimating the overall crime costs attributable to children and young people with conduct disorders or the subsequent adverse outcomes in adulthood. As a result, current estimates of the economic cost of conduct disorder can be assumed to be conservative and the actual cost is more likely to exceed the values reported in the literature when all attributed costs are considered.
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Pattern of behaviour and setting The severity of conduct disorder is not determined by the presence of any one symptom or any particular constellation, but is due to the overall volume of symptoms, determined by the frequency and intensity of antisocial behaviours, the variety of types, the number of settings in which they occur for example home, school, in public and their persistence. Impact At home, the child or young person with a conduct disorder is often exposed to high levels of criticism and hostility, and sometimes made a scapegoat for a catalogue of family misfortunes.
F91 An enduring pattern of behaviour should be present, but no time frame is given and there is no impairment or impact criterion stated. The behaviours can be grouped into four classes: Aggression to people and animals: Differential diagnosis Making a diagnosis of conduct disorder is usually straightforward, but comorbid conditions are often missed.
Differential diagnosis may include: Hyperkinetic syndrome and attention deficit hyperactivity disorder. It is characterised by impulsivity, inattention and motor overactivity. Any of these three sets of symptoms can be misconstrued as antisocial, particularly impulsivity, which is also present in conduct disorders. However, none of the symptoms of conduct disorders are a part of hyperactivity so excluding conduct disorders should not be difficult. A frequently made error, however, is to miss comorbid hyperactivity when conduct disorder is definitely present.
Adjustment reaction to an external stressor. This can be diagnosed when onset occurs soon after exposure to an identifiable psychosocial stressor such as divorce, bereavement, trauma, abuse or adoption. Depression can present with irritability and oppositional symptoms, but, unlike typical conduct disorder, mood is usually clearly low and there are vegetative features difficulties with basic bodily processes, such as eating, sleeping and feeling pleasure ; also, more severe conduct problems are absent.
Early bipolar disorder can be harder to distinguish because there is often considerable defiance and irritability combined with disregard for rules, and behaviour that violates the rights of others. Low self-esteem is the norm in conduct disorders, as is a lack of friends or constructive pastimes. Therefore it is easy to overlook more pronounced depressive symptoms.