The consortium Externalising Behavioural Problems has investigated which approach works among children and young people with behavioural problems that cause a lot of nuisance for themselves and their environment. Care providers can use the results to help young people far more effectively, says Professor of Developmental Psychology Bram Orobio de Castro (University of Amsterdam).
‘The research results definitely meet my expectations’, says consortium leader Orobio de Castro. ‘We have done exactly what we planned to, and clear lessons have emerged from this.’
One outcome is the Decision Tree Externalising Behavioural Problems. This simplifies the joint choice for an appropriate treatment intervention for “difficult” children and young people. Unlike in the original plan, the decision tree has not become an app or website. ‘The user research revealed that care providers were not looking for an app that you could enter information in and receive a ready to use intervention. They mainly want to take each step towards the best decision together with the persons involved. They use “conversations cards” to go through the decision tree together. They find that this works really well. Using this approach, neighbourhood teams talk with the parents about the treatment. According to the care providers, this helps them to make better choices.’
The care organisation Top Groep is a practice partner in the consortium. Director Vanja Ivanisevic and his trainers tried out the strictly set up experiment Think and Act Cool to determine how young people could best learn to manage their anger. The trainers had to follow the researchers’ setup precisely to determine which type of exercise worked the best. That sometimes met with resistance, says Ivanisevic, but in the end everything worked out fine. ‘Due to the strict time planning, we could apply both the cognitive and behaviour module well. We got to the point more quickly and therefore the young people could practice more.’
‘We now know that you can achieve a considerable amount in a few sessions’, says Orobio de Castro. ‘Due to the strict planning, many young people could follow a training which they would otherwise not have received. We were shocked by how large the need is. Most of the participants were in special education or a residential treatment and had considerable problems. None of them had so far received the opportunity of a systematic one-to-one session in which they could practise learning to control their emotions.’
Care providers now realise better treatment choices step-by-step with those involved
Certainly among young people with a mild learning disability (a target group in this experiment) what you do in those few training sessions proved to be very important, according to Orobio de Castro. ‘That concerns both certain exercises and the moment at which you do these. Quickly getting down to work is effective.’ Among the young people with a mild learning disability, the cognitive behavioural exercises, aimed at changing thoughts, are particularly effective. ‘We had not expected that outcome. So now we know which aspect of the module works best for these young people.’
‘For young people without a learning disability there is a stronger variation in the effective aspects’, says Ivanisevic. ‘That also applied to their motivation to work on the problem behaviour’, states Orobio de Castro. ‘The treating professional must then determine what is most appropriate for a certain young person.’
The consortium also investigated the involvement of families in the treatment in residential care. ‘In many places, it is not possible to work in an intensive family- oriented manner’, explains Orobio de Castro. ‘This is also due to practical problems, such as the travel time required. That is a real shame because involving the family has a positive effect on the treatment. We followed the young people during the first year after discharge. The more family-oriented approach was in the residential setting, the better they did at home.’ The consortium hopes to encourage the involvement of families with the Family-Oriented Working Protocol that they have developed.
'Due to the strict setup of the training, we got to the point more quickly and therefore the young people could practise more.'
‘Our trainers have learned that working according to a strict setup and with fewer sessions yields good results’, says Ivanisevic about the participation in the experiment. As far as he is concerned, the collaboration with the consortium can continue. ‘We want to investigate whether we can use the training for other school-age children who suffer from problems with aggression. At present, schools are not able to offer a single approach that is as well received as our approach.’
Orobio de Castro would like to expand the decision tree. ‘The fact that there is a separate guideline for each type of problem is a considerable stumbling block. For example, if a young person who has been registered for the intervention due to fights at school is also found to suffer from depression, then a different guideline applies. We would therefore like to develop a single decision aid for all psychosocial problems.’
Using the new knowledge on a large scale has proven to be more difficult than he had expected, says Orobio de Castro. ‘Even if an intervention is cost-effective, the clients are really enthusiastic about it, and both care providers and schools want to use it, many barriers still remain at municipalities and mental health organisations.’ He therefore calls for neighbourhood teams, parents and teachers to use the knowledge from the decision tree to consult with municipalities about a timely treatment for their children or pupils. ‘We know from foreign research that if you tackle the problems at an early stage, then you can prevent a lot of suffering and societal costs.’
In the consortia Effectiveness of Psychosocial Interventions Youth, researchers and youth care organisations are exploring new possibilities for seven larger substantive themes related to growing up and parenting. The research provides knowledge about which (aspects of) interventions can best be used when, for who and by which persons. The key elements of interventions with proven effectiveness are the starting point for these interventions. Through innovative impact studies, the consortia provide answers to questions such as: What actually makes an intervention effective? Are there effective factors that can be found in all interventions? How can the care provider exert an influence on the impact? And: which interventions or aspects of these are cost-effective? Realising impact studies in an appropriate form is a challenge. Each consortium takes a different approach, but they work together to ensure that their approaches are well aligned with each other. The research from the consortia must improve the interventions and enable professionals and municipalities to choose an effective approach. The outcomes will make it possible to improve the effectiveness of professional practice and provide better help to children and families.
The consortia Effectiveness of Psychosocial Interventions Youth are working on these seven themes:
In the consortia, key elements of interventions will be investigated. But what exactly are those key elements? Key elements are the things that a care provider can do to teach desired behaviour to young people or their parents, guardians or carers. Or to diminish undesirable behaviour. This is given various names in the literature (e.g. components, elements, ingredients, kernels and techniques). We have chosen the term “key element” because this is used by most of the consortia and ties in well with the literature. As it is often not yet clear whether the element actually works, we ought to use the term “potentially effective key elements”. However, that is quite a mouthful. A collection of these key elements defines an intervention. Structural elements also play a role in defining an intervention. For example, the sequence, frequency and intensity of the key elements involved.
Researchers from the consortium first investigated existing studies about interventions with a proven effectiveness to determine their common characteristics and effective elements. Effectiveness was found to be determined by a combination of motivating and cognitive behavioural therapeutic elements combined with a lot of practice in daily life. How and with whom the actual intervention can best be given form – for example with parents, school, children themselves – depends on the age of the child and the nature and severity of the problem. The researchers translated these insights into a decision tree. The decision tree was improved with the help of user research with neighbourhood teams and the municipal health service (GGZ). Furthermore, experiments into the effects of cognitive and behavioural techniques were tested on young people with behavioural problems, some of whom had a mild learning disability. The use of cognitive techniques proved to be mainly effective in this last group of young people. Finally, a large longitudinal study was done into family-oriented working during the residential treatment. This revealed that young people exhibited less problematic behaviour after discharge the more the family was involved in the treatment.
With the decision tree developed, parents and professionals can jointly choose the most suitable intervention and with that the most effective approach for the problems of a specific client or family. Another outcome is the training course Think and Act Cool. Both the cognitive and behavioural effective elements are successful in regulating emotions. Therefore both elements can be used to strengthen existing interventions. Clear indications reveal which element is the most effective for which client, including young people with a mild learning disability. Another outcome is the protocol family-oriented working. This was assessed for usability and effectiveness. The involvement of the young person’s parents and family increases the chances that the behavioural change also continues in the home situation. This approach reduces or prevents the chances of the child falling back into old behaviour when it returns home after being placed in care or a residential treatment. All of the knowledge obtained has been incorporated in an updated guideline, which has been included in the Netherlands Youth Institute file and in manuals for professionals.
Text Veronique Huijbregts. Translation Dave Thomas. Portraits Sannaz Moghaddam. Photography header Studio Oostrum.