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Delinquency: the role of the paediatrician
Symposium: adolescent medicine
Delinquency: the role of the paediatrician
Epidemiology Prevalence The prevalence of conduct disorder is fairly stable across most developed industrialised countries at around 10%, with more boys affected than girls. Adolescent delinquency is much more common. Moffit1 argues that delinquency conceals two distinct categories, each with a unique natural history and aetiology. One group, comprising around 5% of the Dunedin cohort (one of the longest running longitudinal cohort studies of development), engages in anti-social behaviour at every life stage, whereas a larger group (around 20%) is anti-social only during adolescence. Moffit has called these two phenomena ‘life-course-persistent’ and ‘adolescence-limited’ anti-social behaviour. Sex comparisons showed a male:female ratio of 10:1 for childhood-onset delinquency but a sex ratio of only 1.5:1 for adolescent-onset delinquency.2
Elspeth Webb
Abstract Delinquency, that is, criminal behaviour, is one manifestation of antisocial behaviour in adolescence, overlapping considerably with the phenomenon of conduct disorder. Delinquency conceals two distinct categories, each with a unique natural history and aetiology. One group, ‘life-course-persistent’, engages in anti-social behaviour at every life stage, whereas a larger group, ‘adolescence-limited’, is anti-social only during adolescence. Conduct disorder and delinquency have multiple associated risk factors including hyperactivity and impulsivity, low intelligence and attainment, family criminality, poor parental childrearing behaviour, poverty and socially disorganised communities. Paediatricians have a role in both the prevention of delinquency and in the care of affected individuals and their families. Their role in prevention includes: recognition of at-risk children; effective child protection; involvement in parenting programmes; initiatives to reduce poverty and the impact of social disadvantage; and the provision of effective services for hyperactivity and related developmental difficulties. Their role in support and care of affected individuals includes: the provision of both specific and general health services to this group, ensuring that such services are accessible to all affected young people, including those in care and those in prison; and acting as advocates both for individual children and for the whole population.
Aetiology and risk factors Life-course-persistent anti-social behaviours: for this group, adolescent delinquency is part of a developmental continuum (Table 1), manifest in different ways throughout childhood and into young adulthood.3 Conduct disorder and delinquency have multiple associated risk factors that can be classified into genetic/biological and environmental factors. Not all of these will be causal but simply act as markers for risk. Teasing out which factors are causal, which are merely symptomatic and which are confounding is a complex task. In the Cambridge Study in Delinquent Development,4 the most important childhood predictors of adolescent delinquency were: • anti-social child behaviour • impulsivity • low intelligence and attainment • family criminality • poor parental childrearing behaviour • poverty and socially disorganised communities. In the Dunedin study, childhood-onset delinquents had childhoods of inadequate parenting, neurocognitive problems, and temperament and behaviour problems in infancy.3
Keywords anti-social behaviours; conduct disorder; delinquency; healthcare; hyperactivity
Developmental continuum of ‘life-course-persistent’ delinquent adolescents
Introduction ‘Delinquent’ is a legal rather than a medical concept, applied to young people who have broken the law. Delinquency, that is, criminal behaviour, is just one manifestation of the broader concept of anti-social behaviour in adolescence, which includes antisocial attitudes, dishonesty, aggression, drug and alcohol abuse, gambling, sexual promiscuity and violence. For the purpose of this paper, I will use the term ‘delinquency’ to include these broader aspects, and the term ‘conduct disorder’ for anti-social behaviours in childhood. These two phenomena overlap considerably. Conduct-disordered children have a very high likelihood of subsequent delinquency (around 40%).
Infancy
‘Difficult, demanding’
Nursery years
Oppositional behaviours; aggression; deviant or delayed early development Aggression; lying; stealing; bullying; ‘troublesome, disruptive’ (i.e. conduct disorder); learning difficulties Anti-social attitudes; truancy; dishonesty; aggression; drug and alcohol abuse; gambling; sexual promiscuity; violence and law breaking; poor educational outcomes Drug and alcohol abuse; gambling; sexual promiscuity; violence and recidivist criminal behaviours; unemployment
Mid childhood
Adolescence
Young adulthood
Elspeth Webb MBBS MSc FRCP FRCPCH is a Consultant Paediatrician at the University of Wales College of Medicine, Cardiff, UK.
PAEDIATRICS AND CHILD HEALTH 17:11
Table 1
439
© 2007 Elsevier Ltd. All rights reserved.
Symposium: adolescent medicine
Delinquency is claimed to be more prevalent in ethnic minority communities. However, families belonging to these communities experience racial discrimination, are more likely to be unemployed or in low-paid jobs, to live in poor housing, to have significant disparities in health, and to have children who attend poorly resourced schools. It is highly unlikely that ethnicity itself is an important primary risk factor but simply a marker for social disadvantage and discrimination.
well as in the investigation of possible abuse or developmental problems. Paediatricians should be aware of risk factors in the child, the family and the wider community, and be able to link families with appropriate local support services. Effective child protection Given the strong links between early experience of violence, abuse and harsh parenting regimes with later development of conduct disorder and delinquency, it is crucial that children are protected effectively from harm. Although, currently, social services take a lead role in child protection, health professionals –particularly paediatricians and health visitors – are crucial elements of the multiagency child protection team. As the one service that links in with all pre-school children, either within neonatal services or child surveillance, health professionals may be the only members of the multi-agency team who are in a position to recognise such harmful, or potentially harmful, situations and set in motion the child protection process. It is imperative that robust measures are taken, which not only address immediate physical safety, but incorporate a longterm view of minimising the emotional harm that accompanies domestic violence and other emotionally abusive family contexts.
Adolescent-onset delinquency Adolescent-onset delinquents, male and female, do not share the pathological backgrounds found for those with life-course-persistent anti-social behaviours.2 Moffit suggests that this phenomenon is a consequence of what he terms ‘a contemporary maturity gap’ in which, in modern post-industrial societies, sexually and physically mature individuals are infantilised by extended education and delayed work opportunities, resulting in anti-social behaviours ‘that are normative and adjustive’.1 It is an important issue. Around 25% of British men under 25 years of age will have accrued criminal records to accompany them through their adult life, of which over half will have been adolescent-onset delinquents. The relationship between attention-deficit hyperactivity disorder and the development of delinquency Hyperactivity is an irrefutable risk factor for delinquency.3,4 The term ‘attention-deficit hyperactivity disorder’ (ADHD) first appeared in DSM-III-R and is still current in DSM-IV. It includes children with hyperactivity/impulsiveness, children with inattentiveness, or children with both, this latter group being equivalent to hyperkinetic disorder (HD) current in ICD-10. However, only those children with hyperactivity and impulsiveness have an increased risk of future social dysfunction. The diagnosis is a clinical one and based on behavioural criteria. In epidemiological studies carried out by trained and knowledgeable professionals, about 1% of children will fulfil criteria for primary HD,5 with a few percent more fulfilling criteria for ADHD (hyperactive–impulsive subtype). Hyperactivity disorders have very high rates of comorbidity, of which the most common is conduct disorder.4
Parenting programmes Harsh and inconsistent parenting has already been mentioned as strongly associated with delinquency. Unsurprisingly, there is a great deal in the literature on parenting programmes, although much of it relates to programmes directed at families and children with established difficulties.6,7 Parents have long been held responsible for the anti-social behaviours of their offspring and the social ills that accompany them.8 Common sense would suggest that improving parenting would go some considerable way to reducing adolescent delinquency, and there has been a recent refocusing on these measures both in the literature9 and in government policy.10 But parenting happens in context. If that context, for example, extreme poverty, homelessness, violence and social disintegration, ensures that adults cannot function effectively as parents, then interventions that focus exclusively on parenting will fail. As Taylor et al.8 eloquently point out: ‘the current interest in parenting arises as a result of the apparent increase in behavioural problems, child abuse and neglect, juvenile crime, and delinquency. The emergence of (these) social problems is accompanied by explanations that, as they did at the turn of the century, focus on individual rather than societal causes.’ Parenting in the UK, as in the USA, also occurs in the context of a society in which parenting is a low-status occupation. This is linked to the low status of women, given that most parenting continues to be provided by mothers. Many Western governments, particularly Scandinavian countries, have a long history of policies, which underpin the importance of good parenting to society as a whole. These have included protecting parents in the work place with employment policies that acknowledge the dual roles of working parents and enable parents to both contribute to the wider economy and parent effectively. The UK has a poor record in this area. Effective parenting programmes must be implemented in ways which address these contexts. They need to be accompanied by initiatives that increase community cohesiveness and increase the capacity of communities to respond to the needs of children. They must be asset-based, that is, take into account not only the faults but the strengths these families and communities have, and
The role of the paediatrician Paediatricians have important contributions to the prevention of serious anti-social disorders, in the care and management of children with established difficulties, and in advocating for a seriously disadvantaged group of children and young people. In prevention The role of the paediatrician in prevention includes: • recognition of at-risk children • effective child protection • parenting programmes • initiatives to reduce poverty and the impact of social disadvantage • effective services for hyperactivity and related developmental difficulties. Recognition of at-risk children Paediatricians have myriad opportunities to meet at-risk infants and young children: the acute ward, casualty and outpatients, as
PAEDIATRICS AND CHILD HEALTH 17:11
440
© 2007 Elsevier Ltd. All rights reserved.
Symposium: adolescent medicine
children fulfilling list criteria for ADHD/HD without necessarily having primary hyperactivity disorder.5 These children also have high rates of conduct disorder. Some children with primary HD will also be abused, or subject to poor parenting, itself a risk factor for delinquency and for poor outcomes in ADHD (Figure 1). Clinically, this complex inter-relationship between abuse/poor parenting, ADHD and conduct disorder/delinquency can be an extremely challenging diagnostic task requiring the input of a skilled and experienced multidisciplinary team with expertise both in child mental health, paediatrics and child protection.
make broad use of community members in the delivery of services. This will lead to more effective support and empowerment of families to work in full partnership with agencies providing services. The Sure Start programme11 is one example of an intervention which aims to improve parenting by supporting communities in this broad-based manner. Although Sure Start is somewhat limited by being geographically based, thus excluding many poor families, it is important for community paediatricians to establish active partnerships with their local Sure Start projects. Initiatives to reduce poverty and the impact of social disadvantage These are linked with supporting effective parenting. As they have been reviewed recently in this journal, they will not be discussed here.12
General child health services Children and adolescents with significant anti-social behaviours require support from professionals with a variety of skills, necessarily drawn from a range of disciplines and agencies. These young people will be of school age, with most having a statement of special educational need and probably educated outside mainstream settings. They may be in the care of the local authority; a few will be in secure accommodation or prison. As well as emotional and behavioural difficulties, some may also suffer from chronic illness or be disabled. Some will require inpatient treatment for surgery, acute illness, accidental or non-accidental injury, alcohol intoxication and drug overdose. A small proportion will develop very serious mental health problems requiring admission to specialist units. All paediatricians, whether working in a community setting, such as school health or with looked-after children, or in hospital-based services, such as an endocrine clinic or the intensive care unit, will, from time to time, be required to provide care and support to what are, in the main, seriously disadvantaged and often distressed individuals, many of whom have suffered considerable adversity in their lives. It is important that all practitioners work in ways that respect the rights and integrity of these young people, and strive to attain good standards of care despite the challenges that may present in terms of poor compliance. Services offered must be appropriate to their maturity and accessible to this socially marginalised group. Many with chronic illness, for example asthma, chronic middle ear disease or diabetes, may have a long history of suboptimal management of their
Services for ADHD and related developmental difficulties Ideally, primary hyperactivity disorders should be recognised before children present with established behavioural difficulties. Management should be according to a recognised protocol, of which a mainstay is stimulant medication.13 As some children with ADHD have co-morbid neurodevelopmental disorders, paediatricians working with these children should be experienced in their diagnosis and management. They must also work with schools to develop appropriate responses to these children’s needs. It is preferable for children to be recognised as having difficulties rather than to be labelled as ‘bad’. Although there is very good evidence for the effects of stimulant medication on the symptoms of ADHD, medication alone does not appear to affect long-term social and educational outcomes. However, these findings may simply reflect the increased severity of ADHD in medicated children. Medication combined with a positive parenting style is associated with good outcomes.14 In the care and management of affected children and adolescents Delinquency and conduct disorder associated with hyper activity: growing up with abuse and violence can lead to both anxiety and attachment disorder, both of which may lead to
In care hard to place/breakdown of placement
ADHD Exacerbates (Co-morbid with) Increase risk
Mimics
Abuse
Conduct disorder Overactivity distractability (mimics ADHD) Causal
Associated with
Anxiety/disordered attachment
Figure 1 Inter-relationship of attention-deficit hyperactivity disorder, abuse and conduct disorder.
PAEDIATRICS AND CHILD HEALTH 17:11
441
© 2007 Elsevier Ltd. All rights reserved.
Symposium: adolescent medicine
condition, partly a function of their own anti-social behaviours but also subsequent to their social disadvantage. Paediatricians must be able to work effectively with professionals from other disciplines and agencies including, for example, genito-urinary medicine clinics, obstetric and gynaecology services, police, probation officers, psychiatrists, psychologists and professionals working in social services and education, in order to respond effectively to needs of affected children and young people.
2 Moffit TE, Caspi A. Childhood predictors differentiate life-course persistent and adolescence-limited antisocial pathways among males and females. Dev Psychopathol 2001; 13: 355–75. 3 Moffit TE, Harrington HL. Delinquency across development: the natural history of antisocial behaviour in the Dunedin multidisciplinary health and development study. In: Stanton W, Silva PA, eds. The Dunedin study: from birth to adulthood. Oxford: Oxford University Press, 1994. 4 Farrington DP. The development of offending anti-social behaviour from childhood: key findings from the Cambridge study in delinquent development. J Child Psychol Psychiatry 1995; 36: 929–64. 5 Hill P. Attention deficit hyperactivity disorder. Arch Dis Child 1998; 79: 381–4. 6 Woolfenden SR, Williams K, Peat JK. Family and parenting interventions for conduct disorder and delinquency: a meta-analysis of randomised controlled trials. Arch Dis Child 2002; 86: 251–6. 7 Farrinton DP. The challenge of teenage anti-social behaviour. In: Rutter M, ed. Psychosocial disturbances in young people: challenges for prevention. Cambridge: Cambridge University Press, 1995. 8 Taylor J, Spencer N, Baldwin N. Social, economic and political context of parenting. Arch Dis Child 2000; 82: 113–20. 9 Hoghughi M, Speight ANP. Good enough parenting for all children Fa strategy for a healthier society. Arch Dis Child 1998; 78: 293–6. 10 Labour Party Press Briefing. Labour party calls for national debate on parenting: discussion paper on parenting by Jack Straw and Janet Anderson, 1996. http://pages.britishlibrary.net/altcamden/2002/ labparent.htm (accessed February 2003). 11 Hall DMB, Roberts H. What is Sure Start? Arch Dis Child 2000; 82: 435–7. 12 Spencer N. The role of the paediatrician in reducing the effects of social disadvantage on children. Curr Paediatr 1999; 9: 62–7. 13 Hill P, Taylor E. An auditable protocol for treating attention deficit/ hyperactivity disorder. Arch Dis Child 2001; 84: 404–9. 14 Themed issue on ADHD. Pediatr Clin North Am October 1999.
Young people in prison The few adolescents who are in prison are currently a cause of great concern. The most recent statistics reveal that 5530 males and 300 females aged under 18 years went to prison in 2000. There are no resources made available to provide dedicated and appropriate health care to this population. Apart from general health needs, their sexual vulnerability and often established drug habits put them at risk of hepatitis (B and C), HIV and other sexually transmitted diseases. Advocacy Individual advocacy Delinquent behaviours are unattractive, and make it difficult for clinicians to empathise with their rude and anti-social adolescent patient. Dishonesty and aggression are not conducive to establishing good doctor/patient relationships, and can impede the provision of necessary therapeutic interventions or appropriate social and educational support. Despite this, paediatricians must view their delinquent patient as a young person in need first and foremost, and persuade other professionals to follow suit. Group advocacy It is something of a lottery whether these young people are labelled sad, bad or mad, and depending on which, they will end up in the clutches of social services, the criminal justice system or child mental health services. Most will be struggling to some degree or another, whether they are ‘life-course-persistent’ or ‘adolescence-limited’, and need support, not censure, to address their offending behaviours and any underlying causes. Imprisonment seems a particularly unhelpful response. To quote a colleague: ‘it is unbelievably glib to take a teenager who has known humiliation all his life, present him with yet one more humiliation, and think it’ll sort him out.’ Children and young people who have committed very serious crimes, particularly violent crimes, are very likely to be victims and require intensive therapeutic support to come to terms not only with the consequences of their offences, but their own experiences of abuse. We have a duty to speak out for these young people, to persuade the Government and politicians to acknowledge that the blame lies not just with children, their parents, or their teachers, but has roots in attitudes and policies that create social conditions in which delinquency is inevitable. ◆
Practice points • Paediatricians must be aware of risk factors for anti-social behaviours to allow identification of at-risk children • As hyperactivity is one of the most important risk factors, there should be clear local care pathways for the identification and management of affected children • Associated socio-economic factors ensure that delinquent adolescents are likely to have unmet health needs • Meeting these needs requires a co-ordinated and childcentred multi-agency response • Paediatricians have an important role in advocacy, both on behalf of ill or distressed individuals, and for the needs of this group as a whole
Acknowledgements
References 1 Moffit TE. Adolescence-limited, life-course-persistent antisocial behavior: a developmental taxonomy. Psychol Rev 1993; 100: 674–701.
PAEDIATRICS AND CHILD HEALTH 17:11
Thanks to Peter Barbor for the quote in the last paragraph.
442
© 2007 Elsevier Ltd. All rights reserved.
Delinquency: the role of the paediatrician
Epidemiology Prevalence The prevalence of conduct disorder is fairly stable across most developed industrialised countries at around 10%, with more boys affected than girls. Adolescent delinquency is much more common. Moffit1 argues that delinquency conceals two distinct categories, each with a unique natural history and aetiology. One group, comprising around 5% of the Dunedin cohort (one of the longest running longitudinal cohort studies of development), engages in anti-social behaviour at every life stage, whereas a larger group (around 20%) is anti-social only during adolescence. Moffit has called these two phenomena ‘life-course-persistent’ and ‘adolescence-limited’ anti-social behaviour. Sex comparisons showed a male:female ratio of 10:1 for childhood-onset delinquency but a sex ratio of only 1.5:1 for adolescent-onset delinquency.2
Elspeth Webb
Abstract Delinquency, that is, criminal behaviour, is one manifestation of antisocial behaviour in adolescence, overlapping considerably with the phenomenon of conduct disorder. Delinquency conceals two distinct categories, each with a unique natural history and aetiology. One group, ‘life-course-persistent’, engages in anti-social behaviour at every life stage, whereas a larger group, ‘adolescence-limited’, is anti-social only during adolescence. Conduct disorder and delinquency have multiple associated risk factors including hyperactivity and impulsivity, low intelligence and attainment, family criminality, poor parental childrearing behaviour, poverty and socially disorganised communities. Paediatricians have a role in both the prevention of delinquency and in the care of affected individuals and their families. Their role in prevention includes: recognition of at-risk children; effective child protection; involvement in parenting programmes; initiatives to reduce poverty and the impact of social disadvantage; and the provision of effective services for hyperactivity and related developmental difficulties. Their role in support and care of affected individuals includes: the provision of both specific and general health services to this group, ensuring that such services are accessible to all affected young people, including those in care and those in prison; and acting as advocates both for individual children and for the whole population.
Aetiology and risk factors Life-course-persistent anti-social behaviours: for this group, adolescent delinquency is part of a developmental continuum (Table 1), manifest in different ways throughout childhood and into young adulthood.3 Conduct disorder and delinquency have multiple associated risk factors that can be classified into genetic/biological and environmental factors. Not all of these will be causal but simply act as markers for risk. Teasing out which factors are causal, which are merely symptomatic and which are confounding is a complex task. In the Cambridge Study in Delinquent Development,4 the most important childhood predictors of adolescent delinquency were: • anti-social child behaviour • impulsivity • low intelligence and attainment • family criminality • poor parental childrearing behaviour • poverty and socially disorganised communities. In the Dunedin study, childhood-onset delinquents had childhoods of inadequate parenting, neurocognitive problems, and temperament and behaviour problems in infancy.3
Keywords anti-social behaviours; conduct disorder; delinquency; healthcare; hyperactivity
Developmental continuum of ‘life-course-persistent’ delinquent adolescents
Introduction ‘Delinquent’ is a legal rather than a medical concept, applied to young people who have broken the law. Delinquency, that is, criminal behaviour, is just one manifestation of the broader concept of anti-social behaviour in adolescence, which includes antisocial attitudes, dishonesty, aggression, drug and alcohol abuse, gambling, sexual promiscuity and violence. For the purpose of this paper, I will use the term ‘delinquency’ to include these broader aspects, and the term ‘conduct disorder’ for anti-social behaviours in childhood. These two phenomena overlap considerably. Conduct-disordered children have a very high likelihood of subsequent delinquency (around 40%).
Infancy
‘Difficult, demanding’
Nursery years
Oppositional behaviours; aggression; deviant or delayed early development Aggression; lying; stealing; bullying; ‘troublesome, disruptive’ (i.e. conduct disorder); learning difficulties Anti-social attitudes; truancy; dishonesty; aggression; drug and alcohol abuse; gambling; sexual promiscuity; violence and law breaking; poor educational outcomes Drug and alcohol abuse; gambling; sexual promiscuity; violence and recidivist criminal behaviours; unemployment
Mid childhood
Adolescence
Young adulthood
Elspeth Webb MBBS MSc FRCP FRCPCH is a Consultant Paediatrician at the University of Wales College of Medicine, Cardiff, UK.
PAEDIATRICS AND CHILD HEALTH 17:11
Table 1
439
© 2007 Elsevier Ltd. All rights reserved.
Symposium: adolescent medicine
Delinquency is claimed to be more prevalent in ethnic minority communities. However, families belonging to these communities experience racial discrimination, are more likely to be unemployed or in low-paid jobs, to live in poor housing, to have significant disparities in health, and to have children who attend poorly resourced schools. It is highly unlikely that ethnicity itself is an important primary risk factor but simply a marker for social disadvantage and discrimination.
well as in the investigation of possible abuse or developmental problems. Paediatricians should be aware of risk factors in the child, the family and the wider community, and be able to link families with appropriate local support services. Effective child protection Given the strong links between early experience of violence, abuse and harsh parenting regimes with later development of conduct disorder and delinquency, it is crucial that children are protected effectively from harm. Although, currently, social services take a lead role in child protection, health professionals –particularly paediatricians and health visitors – are crucial elements of the multiagency child protection team. As the one service that links in with all pre-school children, either within neonatal services or child surveillance, health professionals may be the only members of the multi-agency team who are in a position to recognise such harmful, or potentially harmful, situations and set in motion the child protection process. It is imperative that robust measures are taken, which not only address immediate physical safety, but incorporate a longterm view of minimising the emotional harm that accompanies domestic violence and other emotionally abusive family contexts.
Adolescent-onset delinquency Adolescent-onset delinquents, male and female, do not share the pathological backgrounds found for those with life-course-persistent anti-social behaviours.2 Moffit suggests that this phenomenon is a consequence of what he terms ‘a contemporary maturity gap’ in which, in modern post-industrial societies, sexually and physically mature individuals are infantilised by extended education and delayed work opportunities, resulting in anti-social behaviours ‘that are normative and adjustive’.1 It is an important issue. Around 25% of British men under 25 years of age will have accrued criminal records to accompany them through their adult life, of which over half will have been adolescent-onset delinquents. The relationship between attention-deficit hyperactivity disorder and the development of delinquency Hyperactivity is an irrefutable risk factor for delinquency.3,4 The term ‘attention-deficit hyperactivity disorder’ (ADHD) first appeared in DSM-III-R and is still current in DSM-IV. It includes children with hyperactivity/impulsiveness, children with inattentiveness, or children with both, this latter group being equivalent to hyperkinetic disorder (HD) current in ICD-10. However, only those children with hyperactivity and impulsiveness have an increased risk of future social dysfunction. The diagnosis is a clinical one and based on behavioural criteria. In epidemiological studies carried out by trained and knowledgeable professionals, about 1% of children will fulfil criteria for primary HD,5 with a few percent more fulfilling criteria for ADHD (hyperactive–impulsive subtype). Hyperactivity disorders have very high rates of comorbidity, of which the most common is conduct disorder.4
Parenting programmes Harsh and inconsistent parenting has already been mentioned as strongly associated with delinquency. Unsurprisingly, there is a great deal in the literature on parenting programmes, although much of it relates to programmes directed at families and children with established difficulties.6,7 Parents have long been held responsible for the anti-social behaviours of their offspring and the social ills that accompany them.8 Common sense would suggest that improving parenting would go some considerable way to reducing adolescent delinquency, and there has been a recent refocusing on these measures both in the literature9 and in government policy.10 But parenting happens in context. If that context, for example, extreme poverty, homelessness, violence and social disintegration, ensures that adults cannot function effectively as parents, then interventions that focus exclusively on parenting will fail. As Taylor et al.8 eloquently point out: ‘the current interest in parenting arises as a result of the apparent increase in behavioural problems, child abuse and neglect, juvenile crime, and delinquency. The emergence of (these) social problems is accompanied by explanations that, as they did at the turn of the century, focus on individual rather than societal causes.’ Parenting in the UK, as in the USA, also occurs in the context of a society in which parenting is a low-status occupation. This is linked to the low status of women, given that most parenting continues to be provided by mothers. Many Western governments, particularly Scandinavian countries, have a long history of policies, which underpin the importance of good parenting to society as a whole. These have included protecting parents in the work place with employment policies that acknowledge the dual roles of working parents and enable parents to both contribute to the wider economy and parent effectively. The UK has a poor record in this area. Effective parenting programmes must be implemented in ways which address these contexts. They need to be accompanied by initiatives that increase community cohesiveness and increase the capacity of communities to respond to the needs of children. They must be asset-based, that is, take into account not only the faults but the strengths these families and communities have, and
The role of the paediatrician Paediatricians have important contributions to the prevention of serious anti-social disorders, in the care and management of children with established difficulties, and in advocating for a seriously disadvantaged group of children and young people. In prevention The role of the paediatrician in prevention includes: • recognition of at-risk children • effective child protection • parenting programmes • initiatives to reduce poverty and the impact of social disadvantage • effective services for hyperactivity and related developmental difficulties. Recognition of at-risk children Paediatricians have myriad opportunities to meet at-risk infants and young children: the acute ward, casualty and outpatients, as
PAEDIATRICS AND CHILD HEALTH 17:11
440
© 2007 Elsevier Ltd. All rights reserved.
Symposium: adolescent medicine
children fulfilling list criteria for ADHD/HD without necessarily having primary hyperactivity disorder.5 These children also have high rates of conduct disorder. Some children with primary HD will also be abused, or subject to poor parenting, itself a risk factor for delinquency and for poor outcomes in ADHD (Figure 1). Clinically, this complex inter-relationship between abuse/poor parenting, ADHD and conduct disorder/delinquency can be an extremely challenging diagnostic task requiring the input of a skilled and experienced multidisciplinary team with expertise both in child mental health, paediatrics and child protection.
make broad use of community members in the delivery of services. This will lead to more effective support and empowerment of families to work in full partnership with agencies providing services. The Sure Start programme11 is one example of an intervention which aims to improve parenting by supporting communities in this broad-based manner. Although Sure Start is somewhat limited by being geographically based, thus excluding many poor families, it is important for community paediatricians to establish active partnerships with their local Sure Start projects. Initiatives to reduce poverty and the impact of social disadvantage These are linked with supporting effective parenting. As they have been reviewed recently in this journal, they will not be discussed here.12
General child health services Children and adolescents with significant anti-social behaviours require support from professionals with a variety of skills, necessarily drawn from a range of disciplines and agencies. These young people will be of school age, with most having a statement of special educational need and probably educated outside mainstream settings. They may be in the care of the local authority; a few will be in secure accommodation or prison. As well as emotional and behavioural difficulties, some may also suffer from chronic illness or be disabled. Some will require inpatient treatment for surgery, acute illness, accidental or non-accidental injury, alcohol intoxication and drug overdose. A small proportion will develop very serious mental health problems requiring admission to specialist units. All paediatricians, whether working in a community setting, such as school health or with looked-after children, or in hospital-based services, such as an endocrine clinic or the intensive care unit, will, from time to time, be required to provide care and support to what are, in the main, seriously disadvantaged and often distressed individuals, many of whom have suffered considerable adversity in their lives. It is important that all practitioners work in ways that respect the rights and integrity of these young people, and strive to attain good standards of care despite the challenges that may present in terms of poor compliance. Services offered must be appropriate to their maturity and accessible to this socially marginalised group. Many with chronic illness, for example asthma, chronic middle ear disease or diabetes, may have a long history of suboptimal management of their
Services for ADHD and related developmental difficulties Ideally, primary hyperactivity disorders should be recognised before children present with established behavioural difficulties. Management should be according to a recognised protocol, of which a mainstay is stimulant medication.13 As some children with ADHD have co-morbid neurodevelopmental disorders, paediatricians working with these children should be experienced in their diagnosis and management. They must also work with schools to develop appropriate responses to these children’s needs. It is preferable for children to be recognised as having difficulties rather than to be labelled as ‘bad’. Although there is very good evidence for the effects of stimulant medication on the symptoms of ADHD, medication alone does not appear to affect long-term social and educational outcomes. However, these findings may simply reflect the increased severity of ADHD in medicated children. Medication combined with a positive parenting style is associated with good outcomes.14 In the care and management of affected children and adolescents Delinquency and conduct disorder associated with hyper activity: growing up with abuse and violence can lead to both anxiety and attachment disorder, both of which may lead to
In care hard to place/breakdown of placement
ADHD Exacerbates (Co-morbid with) Increase risk
Mimics
Abuse
Conduct disorder Overactivity distractability (mimics ADHD) Causal
Associated with
Anxiety/disordered attachment
Figure 1 Inter-relationship of attention-deficit hyperactivity disorder, abuse and conduct disorder.
PAEDIATRICS AND CHILD HEALTH 17:11
441
© 2007 Elsevier Ltd. All rights reserved.
Symposium: adolescent medicine
condition, partly a function of their own anti-social behaviours but also subsequent to their social disadvantage. Paediatricians must be able to work effectively with professionals from other disciplines and agencies including, for example, genito-urinary medicine clinics, obstetric and gynaecology services, police, probation officers, psychiatrists, psychologists and professionals working in social services and education, in order to respond effectively to needs of affected children and young people.
2 Moffit TE, Caspi A. Childhood predictors differentiate life-course persistent and adolescence-limited antisocial pathways among males and females. Dev Psychopathol 2001; 13: 355–75. 3 Moffit TE, Harrington HL. Delinquency across development: the natural history of antisocial behaviour in the Dunedin multidisciplinary health and development study. In: Stanton W, Silva PA, eds. The Dunedin study: from birth to adulthood. Oxford: Oxford University Press, 1994. 4 Farrington DP. The development of offending anti-social behaviour from childhood: key findings from the Cambridge study in delinquent development. J Child Psychol Psychiatry 1995; 36: 929–64. 5 Hill P. Attention deficit hyperactivity disorder. Arch Dis Child 1998; 79: 381–4. 6 Woolfenden SR, Williams K, Peat JK. Family and parenting interventions for conduct disorder and delinquency: a meta-analysis of randomised controlled trials. Arch Dis Child 2002; 86: 251–6. 7 Farrinton DP. The challenge of teenage anti-social behaviour. In: Rutter M, ed. Psychosocial disturbances in young people: challenges for prevention. Cambridge: Cambridge University Press, 1995. 8 Taylor J, Spencer N, Baldwin N. Social, economic and political context of parenting. Arch Dis Child 2000; 82: 113–20. 9 Hoghughi M, Speight ANP. Good enough parenting for all children Fa strategy for a healthier society. Arch Dis Child 1998; 78: 293–6. 10 Labour Party Press Briefing. Labour party calls for national debate on parenting: discussion paper on parenting by Jack Straw and Janet Anderson, 1996. http://pages.britishlibrary.net/altcamden/2002/ labparent.htm (accessed February 2003). 11 Hall DMB, Roberts H. What is Sure Start? Arch Dis Child 2000; 82: 435–7. 12 Spencer N. The role of the paediatrician in reducing the effects of social disadvantage on children. Curr Paediatr 1999; 9: 62–7. 13 Hill P, Taylor E. An auditable protocol for treating attention deficit/ hyperactivity disorder. Arch Dis Child 2001; 84: 404–9. 14 Themed issue on ADHD. Pediatr Clin North Am October 1999.
Young people in prison The few adolescents who are in prison are currently a cause of great concern. The most recent statistics reveal that 5530 males and 300 females aged under 18 years went to prison in 2000. There are no resources made available to provide dedicated and appropriate health care to this population. Apart from general health needs, their sexual vulnerability and often established drug habits put them at risk of hepatitis (B and C), HIV and other sexually transmitted diseases. Advocacy Individual advocacy Delinquent behaviours are unattractive, and make it difficult for clinicians to empathise with their rude and anti-social adolescent patient. Dishonesty and aggression are not conducive to establishing good doctor/patient relationships, and can impede the provision of necessary therapeutic interventions or appropriate social and educational support. Despite this, paediatricians must view their delinquent patient as a young person in need first and foremost, and persuade other professionals to follow suit. Group advocacy It is something of a lottery whether these young people are labelled sad, bad or mad, and depending on which, they will end up in the clutches of social services, the criminal justice system or child mental health services. Most will be struggling to some degree or another, whether they are ‘life-course-persistent’ or ‘adolescence-limited’, and need support, not censure, to address their offending behaviours and any underlying causes. Imprisonment seems a particularly unhelpful response. To quote a colleague: ‘it is unbelievably glib to take a teenager who has known humiliation all his life, present him with yet one more humiliation, and think it’ll sort him out.’ Children and young people who have committed very serious crimes, particularly violent crimes, are very likely to be victims and require intensive therapeutic support to come to terms not only with the consequences of their offences, but their own experiences of abuse. We have a duty to speak out for these young people, to persuade the Government and politicians to acknowledge that the blame lies not just with children, their parents, or their teachers, but has roots in attitudes and policies that create social conditions in which delinquency is inevitable. ◆
Practice points • Paediatricians must be aware of risk factors for anti-social behaviours to allow identification of at-risk children • As hyperactivity is one of the most important risk factors, there should be clear local care pathways for the identification and management of affected children • Associated socio-economic factors ensure that delinquent adolescents are likely to have unmet health needs • Meeting these needs requires a co-ordinated and childcentred multi-agency response • Paediatricians have an important role in advocacy, both on behalf of ill or distressed individuals, and for the needs of this group as a whole
Acknowledgements
References 1 Moffit TE. Adolescence-limited, life-course-persistent antisocial behavior: a developmental taxonomy. Psychol Rev 1993; 100: 674–701.
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Thanks to Peter Barbor for the quote in the last paragraph.
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