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Behavioral problems (other terms include conduct problems) in children and adolescents are difficult not only for the child, but also for their families and community. We examined the effects of interventions for children and adolescents with behavioral problems or criminal behavior. We conducted an overview of reviews and identified eight systematic reviews. These systematic reviews reported on 74 distinct interventions and included about 50,000 children and adolescents younger than 18 years. The results show that it is likely that:
- psychosocial interventions involving parents reduce behavioral problems in children
- psychosocial multisystemic interventions (interventions that involve multiple target groups, e.g. parents and children) reduce behavioral problems in adolescents
- functional family therapy reduces behavioral problems in adolescents with behavioral problems and substance abuse
- parenting programs reduce behavioral problems in children
- family-based interventions reduce antisocial behavior in adolescents with a history of serious offences
We also identified other promising interventions, such as functional family therapy in preventing recidivism among juveniles. However, we are somewhat unsure of the exact effects of these interventions.
For practitioners and policy makers, it is important to note the sustained positive effects of family-based interventions. In particular, parenting programs that help parents change their parenting behavior, can in turn help children adapt positive behavior changes.
Childhood and adolescence are characterized by substantial emotional and social changes. It is during these developmental years that behavioral problems most commonly develop. There is not one agreed definition of child behavioral problems, but it refers to persistent oppositional, aggressive and/or destructive behavior considered outside socially acceptable behavior and norms for that developmental age. It is difficult to estimate the proportion of children with behavioral problems. Yet, studies estimate that approximately 5-10% of children and adolescents in Norway have behavioral problems. These estimates include serious behavioral problems such as delinquency. Even minor behavioral problems can pose a considerable challenge for the child, families, peers, teachers, and society in general. Prospective studies show that behavioral problems in early childhood is a risk factor for a range of mental, physical and social problems in adolescence and adulthood. Therefore, early efforts such as family-based interventions may be key in preventing further behavioral problems.
The aim of this overview of reviews was to assess the effects of interventions for children and adolescents with behavioral problems or criminal behavior.
We aimed to answer the following two questions: 1) What are the effects of interventions for children and adolescents (3-18 years) at risk of developing serious behavioral problems? 2) What are the effects of secondary and tertiary interventions for juveniles (12-24 years)? We conducted a systematic overview of reviews. To identify systematic reviews, a search specialist searched eight international databases in June 2019, including MEDLINE, EMBASE and PsycINFO. We also searched the Norwegian IN-SUM database and manually screened reference lists of relevant systematic reviews and the included systematic reviews. Two researchers independently screened all titles and abstracts from the literature search, and thereafter the full texts, for eligibility according to the inclusion criteria. We used a checklist for methodological quality assessment of systematic reviews and we only included studies with moderate- or high methodological quality. One researcher extracted data from the reviews and a second researcher checked the correctness and completeness of the extracted data. From the included studies we sorted and combined data in text and created tables when relevant. We assessed our certainty in the evidence for the outcomes using the GRADE methodology (Grading of Recommendations Assessment, Development, and Evaluation). We graded the certainty of the evidence as high, moderate, low, or very low. High certainty= We are very confident (certain) that the true effect lies close to that of the estimate of the effect. Moderate certainty= We are moderately confident in the effect estimate: the true effect is probably close to the estimated effect. Low certainty= Our confidence in the effect estimate is limited: the true effect may be markedly different from the estimated effect. Very low certainty = We have very little confidence in the effect estimate: it is unclear whether the intervention has an effect.
We included and reported data from eight systematic reviews. The reviews were published between 2015 and 2019. Five of the reviews had moderate methodological quality, while three had high methodological quality. The reviews included between 14 and 170 primary studies each. In total, we summarized 319 primary studies with 74 different interventions given to approximately 50,000 study participants. The children and adolescents in these reviews were between 1.5 and 18 years and had various behavioural problems (largely described as behavioral problems, externalizing problems, conduct disorder). Some were juveniles. Four reviews included interventions for children and youth with behavioral problems and the remaining four concerned juveniles. There were no eligible systematic reviews with interventions in an institutional setting. Only one of the included reviews specified whether the interventions regarded secondary- or tertiary prevention, and the boundaries between the various levels of prevention were generally unclear, but all concerned early intervention or treatment for behavioural problems.
Effects of interventions for children and adolescents with behavioral problems
Four reviews, with 241 relevant primary studies, investigated the effects of 59 interventions (with approximately 30,000 participants) for children and adolescents with behavioral problems. Compared to control, the results show that:
- parenting programs may reduce behavioral problems in children (multisystemic and non-multisystemic interventions. Multisystemic= interventions that involve multiple target groups, e.g. parents and children)
- the effects of psychosocial interventions (targeting only children, or only adolecents) on behavioral problems in children and adolescents are unclear
- psychosocial interventions (multisystemic or targeting only parents) probably reduce behavioral problems in children
- psychosocial multisystemic interventions probably reduce behavioral problems in adolescents
- functional family therapy probably reduces behavioral problems in adolescents with behavioral problems and substance abuse
- it is unclear whether functional family therapy reduces re-offending in juveniles with behavioral problems
- parenting programs probably reduce behavioral problems in children
Effects of interventions for juveniles
Four reviews with 80 relevant primary studies summarized 15 interventions aimed at preventing re-offending in juveniles aged 10-18 years. Overall, about 21,000 juveniles were included in the studies. Compared to control, the results show that:
- family-based interventions probably reduce antisocial behaviors, such as arrests and serious offences, in adolescents who have committed serious criminal offences
- the effects of interventions aimed at treating sexually offending behavior are unclear with regard to re-offending in youth who have committed sexual offences
- interventions aimed at improving psychosocial functioning may improve psychosocial functioning, such as aggression, in young males who have committed sexual offences
- police-initiated diversion may reduce re-offending in male juveniles
There is extensive research on the effects of both multisystemic and non-multisystemic interventions to reduce behavioral problems in children and adolescents. Overall, research shows that numerous secondary- and tertiary prevention interventions reduce behavioral problems, including delinquency, in children and adolescents.
For the majority of the outcomes in this review we are certain about the direction of effect; i.e. that many of the interventions reduce behavioral problems in children and adolescents. We are less certain about the size of the effects. The strongest evidence is for family-based interventions, especially parenting programs. The results clearly show that both multisystemic and non-multisystemic psychosocial interventions – such as behavioral therapy, Parent-Child Interaction Therapy, multisystemic therapy, the Incredible Years, and Triple P – probably lead to sustained reductions in behavioral problems in children and adolescents. For families with children and adolescents who have behavioral problems, these results support the use of parenting programs, and particularly behavioral therapy. It is possible that such interventions are effective because of improved parent-child interactions. Practitioners should take note of the stronger effects of indicated parenting programs (for high-risk groups) compared to selective programs (for risk groups). With regard to specific techniques that should be a part of parenting programs, the evidence shows there are stronger program effects with positive reinforcement, praise in particular, and natural/logical consequences compared to other techniques. Given the results, the diversity of participants and geographical locations, we consider the results to be transferable to multiple settings, including Norway.
There is no magic bullet for behavioral problems in children and adolescents. However, this systematic review shows there is a set of interventions that appear effective in reducing behavioral problems. For policy makers, stakeholders, and practitioners, it is important to note the sustained positive effects of family-based interventions. In particular, parenting programs that help parents change their parenting behavior, can in turn help children adapt positive behavioral changes.