Antisocial Personality Disorder: The Nice Guideline On Treatment, Management and Prevention

Antisocial
Personality
Disorder
THE NICE GUIDELINE ON TREATMENT,
MANAGEMENT AND PREVENTION
ANTISOCIAL
PERSONALITY
DISORDER:
TREATMENT,
MANAGEMENT AND
PREVENTION
National Clinical Practice Guideline Number 77
National Collaborating Centre for Mental Health

commissioned by the
National Institute for Health
& Clinical Excellence
published by
The British Psychological Society and The Royal College of
Psychiatrists
© The British Psychological Society
& The Royal College of Psychiatrists, 2010
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Contents
CONTENTS
GUIDELINE DEVELOPMENT GROUP MEMBERS 6

1. PREFACE 9
1.1 National guidelines 9
1.2 The national antisocial personality disorder guideline 12
2 ANTISOCIAL PERSONALITY DISORDER 14
2.1 Introduction 14
2.2 The disorder 17
2.3 Aetiology 22
2.4 Presentation in healthcare and other settings 24
2.5 Use of health service resources and other costs 25
2.6 Treatment and management in the NHS 27
2.7 The Dangerous and Severe Personality Disorder initiative 29
2.8 The organisation and coordination of treatment and care 30
2.9 Assessment 31
2.10 Ethical considerations in antisocial personality disorder 32
3 METHODS USED TO DEVELOP THIS GUIDELINE 39
3.1 Overview 39
3.2 The scope 39
3.3 The Guideline Development Group 40
3.4 Clinical questions 42
3.5 Systematic clinical literature review 43
3.6 Health economics methods 53
3.7 Stakeholder contributions 55
3.8 Validation of the guideline 56
4 ORGANISATION AND EXPERIENCE OF CARE 57
4.1 Introduction 57
4.2 Organisation and delivery of care 57
4.3 Training, supervision and support 67
4.4 Service user experience of care and services 74
4.5 Carer experience 85
4.6 Overall summary 87
5 INTERVENTIONS IN CHILDREN AND ADOLESCENTS
FOR THE PREVENTION OF ANTISOCIAL PERSONALITY
DISORDER 89
5.1 Introduction 89
5.2 Risk factors 90
3
Contents
5.3 Early interventions 93

5.4 Interventions for children with conduct problems 107
5.5 Coordination of care 140
6 RISK ASSESSMENT AND MANAGEMENT 143
6.1 Introduction 143
6.2 Assessment of violence risk 143
6.3 Risk management 163
7 INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL
PERSONALITY DISORDER AND ASSOCIATED
SYMPTOMS AND BEHAVIOURS 169
7.1 Introduction 169
7.2 Psychological interventions for antisocial personality disorder 170
7.3 Treatment of comorbid disorders in people with
antisocial personality disorder 196
7.4 Therapeutic community interventions for people
with antisocial personality disorder and associated
symptoms and behaviours 202
7.5 Pharmacological interventions for antisocial personality disorder 208
7.6 Research recommendations 217
8 SUMMARY OF RECOMMENDATIONS 220
8.1 General principles for working with people with
8.2 Prevention of antisocial personality disorder – working
with children and young people and their families 222
8.3 Assessment and risk management of antisocial
personality disorder 227
8.4 Treatment and management of antisocial personality
disorder and related and comorbid disorders 230
8.5 Psychopathy and dangerous and severe personality disorder 231
8.6 Organisation and planning of services 232
8.7 Severity as a potential moderator of effect in group-based
cognitive and behavioural interventions 234
8.8 Group-based cognitive and behavioural interventions
for populations outside criminal justice settings 235
8.9 Effectiveness of multisystemic therapy versus functional
family therapy 235
8.10 Interventions for infants at high risk of developing
conduct disorders 236
8.11 Treatment of comorbid anxiety disorders in
8.12 Using selective serotonin reuptake inhibitors to increase
cooperative behaviour in people with antisocial
personality disorder in a prison setting 237
4
Contents
8.13 A therapeutic community approach for antisocial

personality disorder in a prison setting 238
9. APPENDICES 239
10. REFERENCES 322
11. ABBREVIATIONS 356
5
Guideline development group members
GUIDELINE DEVELOPMENT GROUP MEMBERS
Professor Conor Duggan (Chair, Guideline Development Group)

Professor of Forensic Mental Health, The University of Nottingham;
Honorary Consultant Psychiatrist, Nottinghamshire Healthcare Trust
Dr Stephen Pilling (Facilitator, Guideline Development Group)

Joint Director, The National Collaborating Centre for Mental Health;
Director, Centre for Outcomes Research and Effectiveness, University College
London
Dr Gwen Adshead
Consultant Forensic Psychotherapist, Broadmoor Hospital, West London Mental
Health NHS Trust
Ms Amy Brown
Research Assistant (2007), The National Collaborating Centre for Mental Health
Professor Jeremy Coid

Professor of Forensic Psychiatry, Wolfson Institute of Preventive Medicine, Queen
Mary, University of London
Mr Neil Connelly
Representing the interests of service users and carers
Mr Colin Dearden
Deputy Chief Probation Officer, Lancashire Probation Service
Mr Alan Duncan
Systematic Reviewer, The National Collaborating Centre for Mental Health
Mr Matthew Dyer
Health Economist, The National Collaborating Centre for Mental Health
Dr Brian Ferguson
Consultant Psychiatrist and Clinical Director of Specialist Services, Lincolnshire
Partnership NHS Foundation Trust
Ms Esther Flanagan
Project Manager (2008–2009), The National Collaborating Centre for Mental Health
6
Professor Peter Fonagy

Freud Memorial Professor of Psychoanalysis, University College London; Head of
Research Department of Clinical, Educational and Health Psychology, University
College London; Chief Executive, Anna Freud Centre, London
Dr Savas Hadjipavlou
Programme Director, The Dangerous People with Severe Personality Disorder
(DSPD) Programme, Ministry of Justice
Professor Eddie Kane

Director, Personality Disorder Institute, The University of Nottingham
Mr Ryan Li
Project Manager (2008), The National Collaborating Centre for Mental Health
Professor Anthony Maden

Professor of Forensic Psychiatry, Imperial College;
Honorary Consultant, West London Mental Health NHS Trust
Dr Ifigeneia Mavranezouli
Senior Health Economist, The National Collaborating Centre for Mental Health
Professor James McGuire

Professor of Forensic Clinical Psychology, University of Liverpool; Honorary
Consultant Clinical Psychologist, Mersey Care NHS Trust
Dr Nicholas Meader
Systematic Reviewer, The National Collaborating Centre for Mental Health
Dr Catherine Pettinari
Centre Manager, The National Collaborating Centre for Mental Health
Ms Peny Retsa
Health Economist (2007–2008), The National Collaborating Centre for Mental
Health
Ms Maria Rizzo
Research Assistant (2007–2008), The National Collaborating Centre for Mental
Health
Ms Carol Rooney
Deputy Director of Nursing, St Andrew’s Healthcare
Ms Sarah Stockton
Information Scientist, The National Collaborating Centre for Mental Health
7
Dr Clare Taylor
Editor, The National Collaborating Centre for Mental Health
Dr Nat Wright
Clinical Director for Substance Misuse, HM Prison Service Leeds
8
Preface
1. PREFACE
This guideline has been developed to advise on the treatment and management of
antisocial personality disorder (ASPD). The guideline recommendations have been
developed by a multidisciplinary team of healthcare professionals, a representative
for service users and guideline methodologists after careful consideration of the best
available evidence. It is intended that the guideline will be useful to clinicians and
service commissioners in providing and planning high-quality care for people with
antisocial personality disorder while also emphasising the importance of their expe-
rience of care and that of their carers (see Appendix 1 for more details on the scope
of the guideline).
Although the evidence base is expanding, there are a number of major gaps, and
future revisions of this guideline will incorporate new scientific evidence as it develops.
The guideline makes a number of research recommendations specifically to address
gaps in the evidence base. In the meantime, it is hoped that the guideline will assist
clinicians, people with antisocial personality disorder and their carers by identifying
the merits of particular treatment approaches where the evidence from research and
clinical experience exists.
1.1 NATIONAL GUIDELINES
1.1.1 What are clinical practice guidelines?
Clinical practice guidelines are ‘systematically developed statements that assist

clinicians and patients in making decisions about appropriate treatment for specific
conditions’ (Mann, 1996). They are derived from the best available research evidence,
using predetermined and systematic methods to identify and evaluate the evidence
relating to the specific condition in question. Where evidence is lacking, the guidelines
incorporate statements and recommendations based upon the consensus statements
developed by the Guideline Development Group (GDG).
Clinical guidelines are intended to improve the process and outcomes of healthcare
in a number of different ways. They can:
● provide up-to-date evidence-based recommendations for the management of condi-
tions and disorders by healthcare professionals
● be used as the basis to set standards to assess the practice of healthcare professionals
● form the basis for education and training of healthcare professionals
● assist patients and carers in making informed decisions about their treatment
and care
● improve communication between healthcare professionals, patients and carers
● help identify priority areas for further research.
9
Preface
1.1.2 Uses and limitations of clinical guidelines
Guidelines are not a substitute for professional knowledge and clinical judgement.
They can be limited in their usefulness and applicability by a number of different
factors: the availability of high-quality research evidence, the quality of the method-
ology used in the development of the guideline, the generalisability of research
findings and the uniqueness of individuals with antisocial personality disorder.
Although the quality of research in this field is variable, the methodology used
here reflects current international understanding on the appropriate practice for guide-
line development (AGREE: Appraisal of Guidelines for Research and Evaluation
Instrument; www.agreetrust.org; AGREE Collaboration [2003]), ensuring the collec-
tion and selection of the best research evidence available and the systematic genera-
tion of treatment recommendations applicable to the majority of people with these
disorders and situations. However, there will always be some service users for whom
clinical guideline recommendations are not appropriate and situations in which the
recommendations are not readily applicable. This guideline does not, therefore,
override the individual responsibility of healthcare professionals to make appropriate
decisions regarding the circumstances of the individual diagnosed with antisocial
personality disorder, in consultation with the person or their carer.
In addition to the clinical evidence, cost-effectiveness information, where avail-
able, is taken into account in the generation of statements and recommendations of
the clinical guidelines. While national guidelines are concerned with clinical and cost
effectiveness, issues of affordability and implementation costs are to be determined
by the National Health Service (NHS).
In using guidelines, it is important to remember that the absence of empirical
evidence for the effectiveness of a particular intervention is not the same as evidence
for ineffectiveness. In addition, of particular relevance in mental health, evidence-based
treatments are often delivered as part of an overall treatment programme including a
range of activities, the purpose of which may be to help engage the person and to
provide an appropriate context for providing specific interventions. It is important to
maintain and enhance the service context in which these interventions are delivered;
otherwise the specific benefits of effective interventions will be lost. Indeed, the
importance of organising care in order to support and encourage a good therapeutic
relationship is at times as important as the specific treatments offered.
1.1.3 Why develop national guidelines?
The National Institute for Health and Clinical Excellence (NICE) was established as a
Special Health Authority for England and Wales in 1999, with a remit to provide a single
source of authoritative and reliable guidance for patients, professionals and the public.
NICE guidance aims to improve standards of care, to diminish unacceptable variations
in the provision and quality of care across the NHS and to ensure that the health service
is patient centred. All guidance is developed in a transparent and collaborative manner
using the best available evidence and involving all relevant stakeholders.
10
Preface
NICE generates guidance in a number of different ways, three of which are

relevant here. First, national guidance is produced by the NICE Centre for Health
Technology Evaluation to give robust advice about a particular treatment, intervention,
procedure or other health technology. Second, the NICE Centre for Public Health
Excellence commissions public health guidance focused on both interventions and
broader health promotion activities that help to reduce people’s risk of developing a
disease or condition or help to promote or maintain a healthy lifestyle. Third, the
NICE Centre for Clinical Practice commissions the production of national clinical
practice guidelines focused upon the overall treatment and management of specific
conditions. To enable this latter development, NICE has established seven National
Collaborating Centres in conjunction with a range of professional organisations
involved in healthcare.
1.1.4 The National Collaborating Centre for Mental Health
This guideline has been commissioned by NICE and developed within the National
Collaborating Centre for Mental Health (NCCMH). The NCCMH is a collaboration
of the professional organisations involved in the field of mental health, national
patient and carer organisations, and a number of academic institutions and NICE. The
NCCMH is funded by NICE and is led by a partnership between the Royal College
of Psychiatrists’ research unit and the British Psychological Society’s equivalent unit
(Centre for Outcomes Research and Effectiveness).
1.1.5 From national guidelines to local protocols
Once a national guideline has been published and disseminated, local healthcare
groups will be expected to produce a plan and identify resources for implementation,
along with appropriate timetables. Subsequently, a multidisciplinary group involving
commissioners of healthcare, primary care and specialist mental health professionals,
patients and carers should undertake the translation of the implementation plan into
local protocols taking into account both the recommendations set out in this guideline
and the priorities set in the National Service Framework (NSF) for Mental Health
and related documentation. The nature and pace of the local plan will reflect local
healthcare needs and the nature of existing services; full implementation may take a
considerable time, especially where substantial training needs are identified.
1.1.6 Auditing the implementation of guidelines
This guideline identifies key areas of clinical practice and service delivery for local
and national audit. Although the generation of audit standards is an important and
necessary step in the implementation of this guidance, a more broadly based imple-
mentation strategy will be developed. Nevertheless, it should be noted that the Care
11
Preface
Quality Commission will monitor the extent to which Primary Care Trusts, trusts
responsible for mental health and social care, and Health Authorities have imple-
mented these guidelines.
1.2 THE NATIONAL ANTISOCIAL PERSONALITY

DISORDER GUIDELINE
1.2.1 Who has developed this guideline?
The GDG was convened by the NCCMH and supported by funding from NICE. The
GDG included a representative for service users, and professionals from psychiatry,
forensic psychiatry, clinical psychology, forensic psychology, developmental
psychopathology, social work, nursing, general practice, general practice in prison,
Child and Adolescent Mental Health Services (CAMHS) and the Criminal Justice
System (the Ministry of Justice and the Probation Service).
Staff from the NCCMH provided leadership and support throughout the process
of guideline development, undertaking systematic searches, information retrieval,
appraisal and systematic review of the evidence. Members of the GDG received train-
ing in the process of guideline development from NCCMH staff, and the service users
received training and support from the NICE Patient and Public Involvement
Programme. The NICE Guidelines Technical Advisers provided advice and assistance
regarding aspects of the guideline development process.
All GDG members made formal declarations of interest at the outset, which were
updated at every GDG meeting. The GDG met 13 times throughout the process of
guideline development. It met as a whole and in topic groups; key topics were led by
a national expert in the relevant areas. The GDG was supported by the NCCMH tech-
nical team, with additional expert advice from special advisers where needed. The
group oversaw the production and synthesis of research evidence before presentation.
All statements and recommendations in this guideline have been generated and
agreed by the whole GDG.
1.2.2 For whom is this guideline intended?
This guideline is relevant for people with antisocial personality disorder. It covers the
care provided by primary, community, secondary, tertiary, forensic and other health-
care professionals who have direct contact with, and make decisions concerning, the
care of people with antisocial personality disorder.
The guideline will also be relevant to the work, but will not cover the practice, of
those in:
● occupational health services
● social services
● the independent sector.
12
Preface
The experience of antisocial personality disorder can affect the whole family and
often the community. The guideline recognises the role of both in the treatment and
support of people with antisocial personality disorder.
1.2.3 Specific aims of this guideline
The guideline makes recommendations for the treatment and management of antisocial
personality disorder. It aims to:
● evaluate methods of risk assessment and risk management in antisocial personality
disorder
● evaluate the role of specific psychosocial interventions in the treatment of antisocial
personality disorder
● evaluate the role of pharmacological interventions in the treatment of antisocial
● evaluate the role of interventions to address symptoms and behaviours (including
offending) associated with antisocial personality disorder
● evaluate the role of interventions to manage comorbid disorders
● evaluate interventions to prevent antisocial personality disorder
● promote the implementation of best clinical practice through the development of
recommendations tailored to the requirements of the NHS in England and Wales.
1.2.4 How this guideline is organised
The guideline is divided into chapters, each covering a set of related topics. The first
three chapters provide a general introduction to guidelines, an introduction to antisocial
personality disorder and the methods used to develop this guideline. Chapters 4 to 7
provide the evidence that underpins the recommendations.
Each evidence chapter begins with a general introduction to the topic that sets the
recommendations in context. Depending on the nature of the evidence, narrative
reviews or meta-analyses were conducted, and the structure of the chapters varies
accordingly. Where appropriate, details about current practice, the evidence base
and any research limitations are provided. Where meta-analyses were conducted,
information is given about both the interventions included and the studies considered
for review. Clinical summaries are then given for the evidence presented, and the
rationale behind how the evidence is translated into recommendations is described.
Finally, recommendations related to each topic are presented at the end of each chapter.
On the CD-ROM, full details about the included studies can be found in Appendix 15
and 17. Where meta-analyses were conducted, the data are presented using GRADE
tables in the evidence chapters and forest plots in Appendix 16.
13
Antisocial personality disorder
2 ANTISOCIAL PERSONALITY DISORDER
2.1 INTRODUCTION
This guideline is concerned with the treatment and management of people with
antisocial personality disorder in primary, secondary and tertiary care. Various terms
have been used to describe those who consistently exploit others and infringe society’s
rules for personal gain as a consequence of their personality traits, including antisocial
personality disorder, sociopathy and psychopathy. Both the current editions of the
major classificatory systems—the International Classification of Diseases, 10th revi-
sion (ICD-10; World Health Organization [WHO], 1992) and the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric
Association [APA], 1994)—include antisocial personality disorder as a diagnosis,
although ICD-10 describes it as dissocial personality disorder (WHO, 1992).
Modern concepts of antisocial personality disorder can be traced back to the early
19th century, and, arguably, have always been tightly linked with contemporary
societal attitudes towards criminal justice and civil liberties (Ferguson & Tyrer, 2000).
In the early 1800s clinicians attempted to understand criminals whose offences were
so abhorrent that they were thought to be insane, yet their clinical presentations were
not consistent with recognised mental syndromes. In describing such individuals,
Prichard (1835) coined the term ‘moral insanity’, which was a form of ‘mental
derangement’ in which the intellectual faculties are unimpaired, but the moral princi-
ples of the mind are ‘depraved or perverted’, and the individual is incapable of
‘conducting himself with decency and propriety in the business of life.’
While the strength of the association between antisocial personality disorder and
offending has never been in doubt, there has long been debate about its implications.
In 1874 Maudsley argued that moral insanity was ‘a form of mental alienation which
has so much the look of vice or crime that many people regard it as an unfounded
medical invention’. The crux of the problem was that it was not possible to draw a
meaningful line between two forms of deviance from the norm: criminality on the one
hand and antisocial personality on the other.
Throughout much of the 19th century, the diagnosis of ‘moral insanity’ gained
acceptance across European and American courts of law (which were largely sympa-
thetic to such a defence), until it was replaced by ‘psychopathic inferiority’, described
in a series of influential works by Koch (1891). He believed these abnormal behaviour
states to be the result of ‘a congenital or acquired inferiority of brain constitution’. After
Kraepelin (1905), who created the classification ‘personality disorder’, Schneider
(1923) developed the characterisation of psychopathy as a fundamental disorder of
personality, and he regarded individuals with ‘psychopathic personalities’ as those who
‘suffer through their abnormalities, or through whom society suffers’. This may be seen
as a precursor for modern diagnostic concepts in psychiatry, which place emphasis on
the distress or impairment resulting from disorders (for example, in DSM and ICD).
14
It was Henderson (1939), however, who laid firm foundations for the modern
delineations of antisocial personality disorder, in defining individuals with ‘psychopathic
states’ as those ‘who conform to a certain intellectual standard but who throughout
their lives exhibit disorders of conduct of an antisocial or a social nature’. In the US,
Cleckley (1941) and McCord and McCord (1956) further pushed the notion of the
psychopathic personality as a distinct clinical entity, and established its core criteria
around antisocial behaviours (in particular, aggressive acts). These views have been
extremely influential in shaping later classifications of sociopathy (DSM-I [APA,
1952]), antisocial personality disorder (DSM-II [APA, 1968] onwards), dissocial
personality disorder (ICD) and psychopathy (Hare, 1980).
In 1959, the term psychopathic disorder was incorporated into the Mental Health
Act in the UK, which made it possible for patients to be admitted to hospital compul-
sorily. Psychopathic disorder was defined as ‘a persistent disorder of mind (whether
or not accompanied by subnormal levels of intelligence) which resulted in abnormally
aggressive or seriously irresponsible conduct on the part of the patients, and require
or are susceptible to medical treatment’. This legal definition has been criticised as
poorly defined (for example, it is unclear what constitutes ‘abnormally aggressive’ or
‘seriously irresponsible’ conduct), removed as it is from validated psychiatric classi-
fications of psychopathy (Lee, 1999).
The latter clause of the definition has also been seen as problematic (or at best
optimistic) as it implied that treatment was beneficial or desirable, for which neither
had an evidence base at the time (Ferguson & Tyrer, 2000). While this ‘treatability
criterion’ was introduced to protect the personality disordered individual against
wrongful detention, the definition of ‘treatability’ became so expanded in practice
over the years as to render the term meaningless (Baker & Crichton, 1995). Hence, in
the revised Mental Health Act (HMSO, 2007) a generic term ‘mental disorder’
replaces the various subtypes previously used (that is, mental illness, psychopathic
disorder, mental impairment and severe mental impairment) and, as a consequence,
the treatability test has been replaced with the practitioner needing to be satisfied that
‘appropriate medical treatment is available’ to justify detention for any mental disorder.
Alongside the ambiguity contained in the UK legislation, there is considerable
ambivalence among mental health professionals towards those with personality disorder
in general but particularly towards those with antisocial personality disorder. Some
see this label as sanctioning self-indulgent and destructive behaviour, encouraging
individuals to assume an ‘invalid role’ thereby further reducing whatever inclination
they might have to take responsibility for their behaviour. Others believe that those
with the disorder are better and more appropriately managed by the criminal justice
system. The alternative view is that individuals with antisocial personality disorder
are not only likely to infringe societal norms but also to have complex health needs
that ought to be identified and addressed, either within or alongside the criminal
justice system.
These tensions are evident across all aspects of the disorder, but especially regarding
diagnosis. The criteria for antisocial personality disorder as specified in DSM-IV
have been criticised because of the focus on antisocial behaviour rather than on the
underlying personality structure (Widiger & Corbitt, 1993). This has led to the belief
15
that antisocial personality disorder and its variants may be over-diagnosed in certain
settings, such as prison, and under-diagnosed in the community (Lilienfeld, 1998;
Ogloff, 2006). Moreover, a unique feature of antisocial personality disorder in DSM-IV
is that it requires the individual to meet diagnostic criteria, not only as an adult, but
also as a child or adolescent. This has led to concern that some children might be
labelled as having a personality disorder before their personality has properly developed.
The DSM-IV definition has other major limitations including problems of overlap
between the differing personality disorder diagnoses, heterogeneity among individu-
als with the same diagnosis, inadequate capture of personality psychopathology and
growing evidence in favour of a dimensional rather than a categorical system of clas-
sification (Westen & Arkowitz-Westen, 1998; Clark et al., 1997; Clark, 2007; Tyrer
et al., 2007; Livesley, 2007). Perhaps, most importantly, the individual personality
disorder diagnoses in DSM-IV do not help practitioners to make treatment decisions;
as a result practitioners have to focus on the specific components of personality disorder
(such as impulsivity or affective instability) rather than on the global diagnosis when
deciding on which intervention to use (Livesley, 2007).
Despite these difficulties, there is growing evidence from prospective longitudinal
follow-up studies that identify a number of children whose conduct disorder with
aggressive behaviour persists into adulthood, thereby justifying the approach of DSM
to antisocial personality disorder (Robins et al., 1991; Moffit et al., 2001; Loeber
et al., 2002; Simonoff et al., 2004; De Brito & Hodgins, in press). While the conver-
sion rate from childhood conduct disorder to adult antisocial personality disorder
varies from 40 to 70% depending on the study, the explicit continuity from conduct
disorder in childhood/early adolescence and antisocial behaviour in adulthood has
potential therapeutic implications regarding prevention that are discussed in Chapter 5.
(However, it should be noted that some of this continuity is potentially artefactual,
that is, it is a product of the fact that individuals need a diagnosis of conduct disorder
before they can have one of antisocial personality disorder.) Nevertheless, this
suggests that early intervention in children and adolescents may be effective in
preventing the later development of antisocial personality disorder in adulthood.
A criticism of mental health work in general has been the neglect of examining
personality when assessing Axis I disorders or major mental illnesses (APA, 1980);
hence DSM-III and its successors adopted a bi-axial approach to the diagnosis of
mental disorders, thereby separating mental illnesses on Axis I from personality
disorders on Axis II so that ‘consideration is given to the possible presence of disorders
that are frequently overlooked when attention is directed to the usually more florid
Axis I disorder’ (APA, 1980). One consequence of this approach has been the recog-
nition that Axis I and Axis II conditions often co-occur and that this co-occurrence
usually has a negative effect on the treatment of the Axis I condition (Reich & Vasile,
1993; Cohen et al., 2005; Skodol et al., 2005; Newton-Howes et al., 2006). As
described below, antisocial personality disorder is frequently found to be comorbid
with a number of other mental disorders. Hence, an important aspect of this guideline
is recognising how antisocial personality disorder might negatively moderate the
response to conventional interventions offered for frequently co-occurring conditions
such as substance misuse, depression and other Axis I conditions (Woody et al., 1985;
16
Mather, 1987). It does not, however, offer guidance on the separate management of
these co-occurring conditions.
2.2 THE DISORDER
2.2.1 Symptoms, presentation and pattern of disorder
The diagnostic system DSM-IV, the preferred diagnostic system for this guideline
(see Section 2.2.2), characterises antisocial personality disorder as a pervasive pattern
of disregard for and violation of the rights of others that has been occurring in the
person since the age of 15 years, as indicated by three (or more) of seven criteria,
namely: a failure to conform to social norms; irresponsibility; deceitfulness; indiffer-
ence to the welfare of others; recklessness; a failure to plan ahead; and irritability and
aggressiveness (APA, 1994).
Because those with antisocial personality disorder exhibit traits of impulsivity,
high negative emotionality and low conscientiousness, the condition is associated
with a wide range of interpersonal and social disturbance. While many of these traits
may well be inherited, people with antisocial personality disorder also frequently
grow up in fractured families where parental conflict is the norm and where parenting
is often harsh and inconsistent. As a result of parental inadequacies and/or the child’s
own difficult behaviour (or both), the care of the child is often interrupted and
transferred to agencies outside the family. This in turn often leads to school truancy,
delinquent associates and substance misuse. Antisocial personality disorder is often
associated with low educational attainment. These disadvantages frequently result in
increased rates of unemployment, poor and unstable housing and inconsistency in
relationships in adulthood. Many are imprisoned or die prematurely as a result of
reckless behaviour (Swanson et al., 1994). This catalogue of continuing and multiple
disabilities over time is not so much a description of ‘symptoms’, rather a description
of a broad range of diverse problem areas that are likely to lead to an adverse long-
term outcome.
Consequently, while criminal behaviour is central to the definition of antisocial
personality disorder, this is often the culmination of previous and long-standing
difficulties. Clearly, therefore, there is more to antisocial personality disorder than
criminal behaviour, otherwise all of those convicted of a criminal offence would meet
criteria for antisocial personality disorder and a diagnosis of antisocial personality
disorder would be rare in those without a criminal history. However, this is not the
case. The prevalence of antisocial personality disorder among prisoners is slightly
less than 50% (Fazel & Danesh, 2002; Hart & Hare, 1989; Singleton et al., 1998).
Similarly, epidemiological studies in the community estimate that only 47% of people
meeting criteria for antisocial personality disorder had significant arrest records; a
history of aggression, unemployment and promiscuity were more common than serious
crimes among people with antisocial personality disorder (Robins, 1987; Robins
et al., 1991). These data therefore show that the relationship between antisocial
personality disorder and offending is not straightforward.
17
This position is further strengthened when data on people with personality disorder
(including those in the community) are examined by factor analysis. This approach
consistently produces three or four higher order factors, the most prominent of which
is an ‘antisocial factor’ (Mulder & Joyce, 1997; Blackburn & Coid, 1999; Livesley,
2007; Howard et al., 2008). However, this higher order antisocial factor is more
broadly described than in DSM and includes narcissistic, paranoid and histrionic
traits as well as the more traditionally described antisocial personality disorder items
such as conduct disorder and criminality.
For many clinicians, this broader description of antisocial personality disorder carries
greater conviction than the more behaviourally-based criteria in DSM. Rather than focus-
ing on criminality, mental health professionals are more interested in such features as
unstable interpersonal relationships, disregard for the consequences of one’s behaviour,
a failure to learn from experience, egocentricity, disregard for the feelings of others and
persistent rule breaking (Livesley et al., 1987; Tennant et al., 1990; Livesley, 2007).
Despite disagreements and confusion regarding the diagnosis of antisocial person-
ality disorder, there is a commonly held view that the strict personality component is
characterised by a set of common traits including irresponsible and exploitative behav-
iour, recklessness, impulsivity and deceitfulness (Livesley, 2007). Benjamin (1996)
has expanded on these features and delineates a characterisation that seeks to provide
a description of the internal mental mechanisms at play in the disorder. She describes
the core features of those with antisocial personality disorder as consisting of:
‘a pattern of inappropriate and unmodulated desire to control others, imple-

mented in a detached manner. There is a strong need to be independent, to resist
being controlled by others, who are usually held in contempt. There is a willingness
to use untamed aggression to back up the need for control or independence. The
[antisocial personality] usually presents in a friendly, sociable manner, but that
friendliness is always accompanied by a baseline position of detachment. He or
she doesn’t care what happens to self or others’. (Benjamin, 1996, p. 197;
emphasis added by GDG)
At the present time, DSM is undergoing major revision (as DSM-V), and it is hoped
that there will be a reduced emphasis on criminal behaviour and an increased empha-
sis on the interpersonal deficits to characterise antisocial personality disorder.
2.2.2 Diagnosis
DSM-IV
Taking account of criticisms of DSM-III (APA, 1980) and DSM-III-R (APA, 1987)
that the criteria were too behaviourally focused, some effort was made in the DSM-
IV revision to produce a more trait-based description. Specifically, there was a field
trial comparing Robins’ emphasis on the continuity of conduct disorder in childhood
with adult antisocial personality disorder with the more trait-based personality crite-
ria of the Psychopathy Checklist-Revised (PCL-R; Robins, 1987). Despite this work
18
and its implications, the changes introduced for DSM-IV were modest (Millon &
Davis, 1996; Hare et al., 1991). Hence, as described above, the principal criteria for
antisocial personality disorder in DSM-IV are:
‘a pervasive pattern of disregard for and violation of the rights of others occur-
ring since 15 years, as indicated by three (or more) of the seven criteria that
include four in the interpersonal realm (including a failure to conform to social
norms, irresponsibility, deceitfulness and indifference to the welfare of others);
one in the behavioural realm (recklessness); one in both the behavioural and
cognitive domain (a failure to plan ahead), and finally, one in the mood domain
(irritability and aggressiveness)’. (Millon & Davis, 1996)
One of the concerns of many authors (for example, Kernberg, 1992) is the degree to
which antisocial personality disorder, with its interpersonal exploitativeness, can be
usefully distinguished from narcissistic personality disorder; indeed, they are often
found to co-occur. Millon and Davis (1996) offer useful guidance:
‘the antisocial is driven, first, to benefit himself and, second, to take vigorous
action to see that these benefits do accrue to himself. This pattern is similar to, yet
different, than seen in narcissists, where an unjustified self-confidence assumes
that all that is desired will come to them with minimal effort on their part. The
antisocial assumes the contrary. Recognising by virtue of past experience that
little will be achieved without considerable effort, cunning and deception, the
antisocial knows that desired ends must be achieved from one’s own actions.
Moreover, these actions serve to fend off the malice that one anticipates from
others, and undo the power possessed by those who wish to exploit the antisocial.’
Not only does this usefully separate antisocial personality disorder from narcissistic
personality disorder, but it also describes a core component of antisocial personality
disorder, namely that one needs to actively look after oneself because it is believed
that no one else will do so.
ICD-10
In ICD-10 (WHO, 1992), the term used is dissocial personality disorder, rather than
antisocial personality disorder. In summary, its criteria focus more than DSM-IV on
interpersonal deficits (for example, incapacity to experience guilt, a very low toler-
ance of frustration, proneness to blame others, and so on) and less on antisocial
behaviour per se. It does not require symptoms of conduct disorder in childhood. This
definition of dissocial personality disorder has been criticised for including features
of aggressive/sadistic personality disorder that cannot be accommodated elsewhere in
ICD-10 (Millon & Davis, 1996).
Psychopathy
Cleckley (1941), in his influential book The Mask of Sanity, attempted to identify the
underlying traits of those who behaved in an exploitative manner and thereby
19
provided a description of psychopathy. Building on Cleckley’s work, Hare and

colleagues (2000) produced two separate factors to describe antisocial behaviour in
their development of the Psychopathy Checklist–Revised (PCL-R; Hare, 1991). The
first of these related to the more narcissistic variant of personality abnormality,
emphasising traits such as selfishness, egocentricity and callousness. The second
referred to a more antisocial lifestyle with frequent criminal behaviour, early and
persistent delinquency, a low tolerance for frustration, and so on. More recent work
has expanded the description of psychopathy as comprising three or four factors. The
four factor model (Neumann et al., 2007) consists of:
a) an interpersonal factor that includes superficial charm, grandiosity, pathological
lying and manipulation
b) an affective factor that includes callousness, lack of remorse, shallowness and
failure to accept responsibility
c) an impulsive lifestyle factor that comprises impulsivity, sensation seeking and
irresponsibility
d) an antisocial factor that involves general rule breaking.
The alternative three-factor model of Cooke and Mitchie (2001) differs in that it
does not include an antisocial factor because this is seen as a concomitant, rather then
a core feature, of psychopathy (Blackburn, 2007). This disagreement about whether
criminal behaviour is a core or concomitant feature of psychopathy was echoed in the
GDG’s discussion of the concept of antisocial personality disorder.
The disorder of psychopathy, while associated with antisocial personality disorder,
is distinct in that while most of those who score highly on the PCL-R (Hare et al.,
2000) will also meet criteria for antisocial personality disorder, only about 10% of
those with antisocial personality disorder meet criteria for psychopathy as measured
by the PCL-R. In this guideline, psychopathy is referred to only briefly and with
reference to practice in tertiary care. The practical implications of this are that those
who score highly on the PCL-R and who present to services, or are coerced into doing
so, will do so largely to tertiary services.
Although there is disagreement on the diagnostic criteria for antisocial personal-
ity disorder, the criteria used in DSM-IV (APA, 1994) have been adopted in this
guideline in order to provide a primary diagnostic anchor point. In addition, nearly all
of the evidence examining the efficacy of the interventions focuses on those with a
DSM diagnosis. However, evidence from other classificatory systems, that is, dis-
social personality disorder in ICD-10 (WHO, 1992) and ‘psychopathy’ (Hare, 1991),
is used where relevant.
2.2.3 Course and prognosis
Gender affects both the prevalence of antisocial personality disorder (see Section
2.2.4) and its course: it is more common in men who are also more likely to persist
with their antisocial behaviour when compared with women. For instance, Guze
(1976) found that most incarcerated male felons were still antisocial by interview at
follow-up (87% at 3 years, 72% at 9 years) while Martin and colleagues (1982) found
20
that among women, only 33% were engaging in criminal behaviour at 3 years and
only 18% at 6 years. Nonetheless, follow-up studies also demonstrate a reduction in
the rates of re-offending in men over time (Grilo et al., 1998; Weissman, 1993).
However, Black and colleagues (1995), in one of the few long-term follow-up stud-
ies of men with antisocial personality disorder showed that while the men had
reduced their impulsive behaviour (and hence their criminality) with the passage of
time, they continued to have significant interpersonal problems throughout their lives
(Paris, 2003).
Antisocial personality disorder is associated with an increase in mortality.
Martin and colleagues’ (1985) follow-up of 500 psychiatric outpatients in St Louis
in the US found that those with antisocial personality disorder had a greatly
increased standardised mortality rate (SMR) compared with other psychiatric
conditions (SMR ⫽ 8.57, p ⫽ 0.01). An even more striking finding was provided
by Black and colleagues (1996) in their follow-up of men with antisocial personal-
ity disorder. They found that young men with antisocial personality disorder had a
high rate of premature death, with those under the age of 40 having an SMR of 33
with the SMR diminishing with increasing age. This increased mortality was due to
not only an increased rate of suicide, but to reckless behaviour such as drug misuse
and aggression.
One of the most striking findings from the literature is that a relatively small
number of offenders commit the majority of crimes. For instance, it is known that
5 to 6% of offenders are responsible for 50% of recorded crimes (Farrington et al.,
1986). Furthermore, those who commit the majority of crimes, continue to do so
throughout most of their life. This is in contrast to the large number of offenders who
desist from criminal activity after adolescence. This observation has led to the
concept of ‘life-course-persistent offenders’ as opposed to ‘adolescence-limited
offenders’ (Moffitt, 1993). From the longitudinal Dunedin study, Moffitt was able to
characterise life-course-persistent offenders as having inherited or constitutional
neuropsychological difficulties that later interact with a criminological environment
to produce a phenotype of persistent offending (Moffitt, 1993).
2.2.4 Prevalence of antisocial personality disorder and related conditions
The prevalence of antisocial personality disorder in the general population varies

depending on the methodology used, and the countries studied, but all show that the
condition is much more prevalent among men. The lifetime prevalence in two North
American studies was 4.5% among men and 0.8% among women (Robins et al.,
1991) and 6.8% among men and 0.8% in women (Swanson et al., 1994). Two
European studies found a prevalence of 1.3% in men and 0% in women (Torgensen
et al., 2001) and 1% in men and 0.2% in women (Coid et al., 2006). Despite these
relative differences between North American and European studies, the rates of
antisocial personality disorder reported indicate that even with the most conservative
estimates antisocial personality disorder has the same prevalence in men as schizo-
phrenia, which is the condition that receives the greatest attention from mental health
21
professionals. While the incidence of antisocial personality disorder in women may

be lower and the threshold for entry to services such as forensic services or the
criminal justice system higher, there is some evidence to suggest that women with
antisocial personality disorder (Yang & Coid, 2007) have greater severity of problems
characterised by more complex comorbidities for both Axis I and Axis II disorders
and corresponding poor outcomes (for example, Galen et al., 2000).
Antisocial personality disorder is common in prison settings. Surveys of prison-
ers worldwide indicate a prevalence of antisocial personality disorder of 47% for men
and 21% for women (Fazel & Danesh, 2002). In the UK prison population, the
prevalence of people with antisocial personality disorder has been identified as 63%
male remand prisoners, 49% male sentenced prisoners, and 31% female prisoners
(Singleton et al., 1998). By contrast, the prevalence of psychopathy in UK prisoners
is only 4.5% using a PCL-R score of ⱖ30, and 13% using a score of ⱖ25 (Hare
et al., 2000).
Significant comorbidity exists between antisocial personality disorder and many
Axis I conditions. For instance, Swanson and colleagues’ (1994) community study
showed an increased prevalence of ‘nearly every other psychiatric disorder . . . with
90.4% having at least one other psychiatric disorder.’ Substance misuse is the most
important disorder co-occurring with antisocial personality disorder. In the
Epidemiological Catchment Area (ECA) study, when men with and without antiso-
cial personality disorder were compared, those with antisocial personality disorder
were three and five times more likely to misuse alcohol and illicit drugs (Robins et al.,
1991). It is also important to note that while women have a significantly lower preva-
lence of antisocial personality disorder than men, those women with antisocial
personality disorder have an even higher prevalence of substance misuse when
compared with men (Robins et al., 1991; Compton et al., 2005).
For other conditions, half of those with antisocial personality disorder will have
co-occurring anxiety disorders (Goodwin & Hamilton, 2003) and a quarter will have
a depressive disorder (Lenzenweger et al., 2007). These co-occurring Axis I condi-
tions are important because the presence of antisocial personality disorder is likely to
be a negative moderator of treatment response when these conditions are treated by
conventional approaches.
2.3 AETIOLOGY
2.3.1 Gene-environment interactions
As with most psychiatric conditions, antisocial personality disorder is construed as

having both a biological and psychosocial aetiology. While it has long been recog-
nised that genes contribute to antisocial behaviour, this field has advanced signifi-
cantly within the past decade with more sophisticated designs and larger twin and
adoptive samples. Two developments are especially noteworthy.
First, there is evidence that there is heterogeneity in the antisocial behaviour
exhibited by young children. For instance, Viding and colleagues (2005) have shown
22
that by subtyping the antisocial behaviour in 7-year-old twins into those children with
and without callous and unemotional traits (that is, AB/CU⫹ and AB/CU⫺ respec-
tively), that there was a much stronger heritability in the former (of 0.81 versus 0.30
respectively). Moreover, there is evidence that children who offend early and do so
with greater aggression have an increased heritability for this behaviour (see a review
by Viding et al., 2008). Hence, there is some evidence that this aggressive antisocial
behaviour is ‘hardwired’ in the brain from an early age.
Second, despite evidence for this deterministic ‘hardwired’ process, current
thinking recognises that differing gene/environmental mechanisms are at play in such
children. Hence, children who are genetically vulnerable to behaving in an antisocial
manner are likely to also suffer from harsh and inconsistent parenting that, in turn,
they may exacerbate by provoking negative responses with their behaviour. Adoption
studies show an interactive effect of genetic vulnerability with an adverse environ-
ment so that there is more pathology than one would expect from either acting alone
or in combination (Cadoret et al., 1995).
This interactive effect of genes and environment suggests that the genetic risk
might be moderated by intervening to reduce negative responses from the parent (for
example, parent-training programmes, multisystemic therapy, and so on). Knowledge
of the genetic vulnerability may inform programme content and delivery and so
increase its effectiveness. For instance, children with callous and unemotional traits
respond badly to being punished but positively to rewards and therefore require
programmes tailored to their specific needs (see Chapter 5).
2.3.2 Biological markers for aggressive behaviour
Cross-sectional studies comparing those with and without aggressive behaviour have
demonstrated robust differences in physiological responses and in brain structure and
function in these groups (see a review by Patrick, 2008). For instance, individuals
prone to aggression have enhanced autonomic reactivity to stress, enhanced EEG
slow wave activity, reduced levels of brain serotonin (Coccaro et al., 1996a; Dolan
et al., 2001) and dysfunction in the frontocortical and limbic regions that mediate
emotional processing (Intrator et al., 1997; Raine et al., 2000, Blair et al., 2006).
While this increase in understanding in the biology of antisocial behaviour is to be
welcomed, it is subject to the following limitations. Most of the studies carried out focus
on those with aggressive behaviour and psychopathy rather than on antisocial personal-
ity disorder. For instance, children and adolescents who are aggressive have lower levels
of autonomic arousal but an enhanced autonomic reactivity to stress (Lorber, 2004);
whereas adults who score high on the Psychopathy Checklist have reduced autonomic
activity in relation to stress. The studies suffer, furthermore, from failing to control for
confounding factors, such as comorbidity and substance misuse and from a concentra-
tion on simple neuropsychological processes such as motor impulsivity or recognition
of basic emotions, rather than on more complex behaviour and moral decision making.
Finally, they appear to be disconnected from routine clinical work and hence are
unlikely to influence current clinical decision making (Duggan, 2008).
23
In addition to these biological factors, there are numerous adverse environmental

influences that are important, including harsh and inconsistent parenting, social
adversity, poverty and associating with criminal peers.
This consequence of the interaction between the various biological vulnerabilities
and being brought up in an adverse environment has been articulated by Dodge
(2000) who describes a ‘child [who] never acquires the social skills and regulatory
mechanisms necessary to navigate the world of adolescence. The child consistently
fails to attend to relevant social cues, readily makes hostile attributions about peers
and adults, accesses aggressive responses in social situations, and either impulsively
performs these responses without thinking about their consequences or evaluates their
likely outcomes as acceptable and selects them’ (p. 458).
2.4 PRESENTATION IN HEALTHCARE AND OTHER SETTINGS
Because people with antisocial personality disorder externalise their difficulties, it is

not surprising that they rarely present in healthcare settings requiring help to deal
directly with problems arising from their personality disorder. In general, therefore,
they can be described as ‘treatment rejecting’ rather than ‘treatment seeking’ (Tyrer
et al., 2003). This is in contrast to people with borderline personality disorder, many
of whom do seek treatment, albeit in a dysfunctional manner (Benjamin, 1993). This
is important in that it underscores Coid’s (2003) advice that those who provide mental
health services ought not to assume that the frequency of help-seeking behaviour is
necessarily an accurate indication of either the prevalence of the condition or its
therapeutic need.
When people with antisocial personality disorder do present for treatment, this is
usually either for a comorbid condition and/or they have been coerced into treatment
by a relative or some external authority in a crisis. Given that those with antisocial
personality disorder actively resist having to accept help, and that coercion into treat-
ment directly challenges their core personality structure, it is clear that therapeutic
interventions are also likely to be under threat in such circumstances. Hence, one
might expect a high drop-out rate from treatment and indeed that is what has been
found (Huband et al., 2007). Nonetheless, people with antisocial personality disorder
do present to healthcare services (either willingly or otherwise), so it is important that
such services have an understanding of the core personality issues so that they can
respond appropriately.
2.4.1 Treatment attrition
Dropping out of treatment is a particular problem in the treatment of personality

disorder (Skodol et al., 1983; Gunderson et al., 1989) and those with antisocial
personality disorder have several characteristics (including a hostile attributional
style, low educational attainment and impulsivity) that place them at high risk of
doing so. Dropping out of treatment is not only a waste of an expensive resource for
24
the service provider but also for the patients because their outcome is often worse
than if they had never been treated (McMurran & Theodosi, 2007). This suggests that
especial care needs to be taken in the management of those with antisocial personality
disorder to identify indicators of drop out and actively address them.
Patient preference, information and consent

In a population that is largely ‘treatment rejecting’, issues concerning patient prefer-
ence and information can be challenging. However, given the propensity of people
with antisocial personality disorder not only to reject treatment but also to drop out
of treatment, additional efforts to engage people may be required. These issues are
dealt with more fully in Chapter 4 while ethical issues are covered further in
Section 2.10.
2.5 USE OF HEALTH SERVICE RESOURCES AND OTHER COSTS
It is important to recognise that while antisocial personality disorder is associated

with considerable harm to the individual with the condition, this harm extends more
broadly to have an impact not only on immediate family members, but on society at
large. Extended harm leads not only to high levels of personal injury and financial
damage for victims but also to increased costs of policing, security, and so on (Welsh
et al., 2008). Recognition of these extended costs is important in making a case for
what appear to be, on occasion, expensive interventions.
The evidence on the health service costs of antisocial personality disorder is
limited. In addition to the paucity of research there are problems in interpreting the
current evidence base. There are a number of reasons for this. Health service use
specific to antisocial personality disorder is often difficult to estimate because of the
significant comorbidity between Axis I and Axis II disorders. In addition, many
individuals with the condition do not present for treatment except under duress (for
example, if they require drug detoxification in prison) and, even in cases where the
person presents, the condition is often not recognised (for example, because people
presenting require emergency treatment for an alcohol-related physical health prob-
lem or treatment for another comorbid condition). However, this apparent treatment
avoidance can be construed more positively in that many with antisocial personality
disorder do not seek help because they are not aware of the interventions available,
or, when they do present for help, their presentation is so coloured by the nature of
their personality disorder that services are reluctant to respond positively to their
demands. This guideline recognises that those with antisocial personality disorder
have many unmet needs and that current service provision may need to be reconfig-
ured in order to meet their expectations.
Healthcare service costs incurred by people with dangerous and severe person-
ality disorder have been estimated in a study conducted in Rampton, the high secure
hospital in Nottinghamshire (Barrett et al., 2005). The mean cost per person receiving
care at the hospital over a 6-month period was £65,545 (2002/03 prices), but there
was considerable variation among individuals, with the 6-month cost ranging from
25
£59,000 to £83,000. No other evidence on health and social care costs directly asso-
ciated with antisocial personality disorder was identified in the existing literature.
However, more extensive research has been undertaken on the costs associated with
conduct disorder. Romeo and colleagues (2006) estimated such costs in a sample of
young children (aged from 3 to 8 years) with conduct disorder in the UK, adopting a
broad societal perspective that included health services, education, social care and
costs borne to the family. The mean annual cost per child reached £6,000 (2002/03
prices); the greatest component of this cost (about 78%) reflected non-service costs
to the family, comprising mainly extra time spent on household tasks. Costs to educa-
tion services and to the NHS approximated £1,300 and £550 per year, respectively.
Another study conducted in the UK compared the total costs incurred by children
with conduct disorder, children with some conduct disorder traits and children with-
out conduct disorder, from the age of 10 and up to the age of 28 years (Scott et al.,
2001a). A wide perspective was adopted in this study, which considered special
educational, health, foster and residential care services, crime costs, state benefits
received in adulthood and breakdown of relationships reflected in domestic violence
and divorce. The total cost per person diagnosed with conduct disorder as a child
reached £70,000 (1998 prices); the respective cost per person with conduct problems
in childhood exceeded £24,000. In contrast, the cost per child in the control group
was only £7,400 over 18 years (that is, from 10 to 28 years of age). The most signif-
icant cost element in the group that had been diagnosed with conduct disorder in
childhood was the cost associated with criminal behaviour—this amounted to 64% of
the total cost. Special education services incurred 18% of the total cost, foster and
residential services 11%, state benefits 4%, while NHS costs constituted only 3% of
the total cost incurred by this population. Similar findings were reported in a US
study that compared the costs of children with conduct disorder, oppositional defiant
disorder and elevated levels of problem behaviour, with a group of children without
any of these disorders (Foster et al., 2005): the 4-year health and criminal justice costs
of children with conduct disorder were twice as much as the respective costs incurred
by children with oppositional defiant disorder, 1.7 times higher than costs of children
with problem behaviour, and more than 3 times the costs recorded for the control
group. Comorbid conduct disorder has been shown to significantly increase costs in
adults who were diagnosed with depression in childhood: Knapp and colleagues
(2002) demonstrated that adults who had depression and comorbid conduct disorder
as children incurred more than double the costs compared with those who were diag-
nosed with depression (but no conduct disorder) in childhood. Conversely, it has been
suggested that comorbid depression increases costs incurred by young offenders in
custody or in contact with youth offending teams (Barrett et al., 2006). Besides
depressed mood, younger age was also shown to result in an increase in total costs.
For those who engage in criminal behaviour there are the obvious costs of such
behaviour, including emotional and physical damage to victims, damage to property,
police time, involvement with the criminal justice system and prison services. Brand
and Price (2000) estimated that the total cost of crime in England and Wales reached
£60 billion in 1999/2000. This estimate included costs incurred in anticipation of
crime, such as security expenditure and insurance administration, costs directly
26
resulting from crime, such as stolen or damaged property, lost output, emotional and
physical impact on victims, health and victim services, as well as costs to the criminal
justice system, including police services. Nevertheless, other important consequences
of crime, such as the fear of crime and its impact on quality of life were not taken into
account in the estimation of the above figure. Fear of crime and other intangible costs
to crime victims, such as pain, grief and suffering, have been the subject of research
of a growing literature aiming at estimating the wider cost implications of crime to
the society (Dolan et al., 2005; Dolan & Moore, 2007; Dolan & Peasgood, 2007;
Dolan et al., 2007; Loomes, 2007; Semmens, 2007; Shapland & Hall, 2007). Mental
healthcare needs of victims of crime should not be ignored because these have been
shown to substantially contribute to the costs associated with crime: a US study esti-
mated that crime victims represented about 20 to 25% of people visiting mental
healthcare professionals, incurring a cost to mental healthcare services of between
$5.8 and $6.8 billion in the US in 1991 (Cohen & Miller, 1998).
Equally important to the above costs are the costs associated with lost employment
opportunities, family disruption, relationship breakdown, gambling and problems
related to alcohol and substance misuse (Myers et al., 1998; National Research
Council, 1999; Home Office & Department of Health, 2002). Therefore, the financial
and psychological implications of antisocial personality disorder, offending behaviour
and conduct disorder are likely to be wider than those indicated by the figures
reported in the published literature. Efficient use of available healthcare resources is
required to maximise the benefits for people with these conditions, their family and
carers, and society in general.
2.6 TREATMENT AND MANAGEMENT IN THE NHS
While the ‘therapeutic gloom’ surrounding the condition identified by Aubrey Lewis in
1974 has been lightened with many more initiatives available to enable staff to intervene
in this group (Department of Health, 2003), nonetheless it remains the case that high-
quality evidence of efficacy for these initiatives is lacking. For instance, 19 years after
Lewis’s pessimistic assessment, Dolan and Coid (1993) in their review of the treatment
of psychopathic and antisocial personality disorder concluded that the evidence base for
such treatments was poor. They could identify only a small number of studies and these
were limited by poor methodology and lack of long-term follow-up.
Ten years after the Dolan and Coid (1993) review, further work failed to uncover a
more credible evidence base (Warren et al., 2003). In 2007, the situation was similar: two
systematic reviews of psychological and pharmacological treatments could locate only
five trials in the treatment of antisocial personality disorder that met Cochrane criteria for
an acceptable randomised controlled trial (RCT) (Duggan et al., 2007a, Duggan et al.,
2007b). More significantly, all of these five trials examined the effect of the intervention
to reduce substance misuse in those with antisocial personality disorder, rather than the
characteristics of antisocial personality disorder per se. A failure to achieve a consensus
on defining the trial population and on the outcomes that were relevant was identified as
the main reasons for this lack of progress (Duggan et al., 2007a, Duggan et al., 2007b).
27
2.6.1 Pharmacological treatments
Although there is no reliable estimate of the use of pharmacological treatments

among those with antisocial personality disorder in the literature, a varied list of drugs
are commonly prescribed. Dolan and Coid (1993) reviewed the use of numerous drug
groups including antidepressants, hypnotics, anxiolytics, antiepileptics and central
nervous system stimulants in people with antisocial personality disorder. The research
evidence justifying the use of these interventions was found to be limited.
As a DSM diagnosis has limited uses for treatment planning (Livesley, 2007),
Soloff (1998) recommended a symptom-orientated approach to guide the use of phar-
macotherapy in personality disorder. Among his symptom domains, the following are
potentially relevant for antisocial personality disorder: impulse–behavioural, affective
and cognitive-perceptual (because of associated paranoid features). He found
evidence favouring selective serotonin reuptake inhibitors (SSRIs) and antimanic
drugs for impulsive dyscontrol; SSRIs and other antidepressants for emotional
dysregulation and low dose antipsychotics for cognitive-perceptual abnormalities.
Many of the trials in his review focused on borderline personality, and it remains to
be evaluated as to whether effective reduction of anger or impulsiveness in that group
might be extrapolated to people with antisocial personality disorder (Soloff, 1998).
2.6.2 Psychological treatments
Unfortunately, the evidence base for psychological treatments for antisocial person-
ality disorder is as limited as that for pharmacological treatments (Duggan et al.,
2007). Much more emphasis has been placed on the psychological treatment of other
personality disorders, primarily borderline personality disorder (for example,
Kernberg, 1984; Linehan & Dimeff, 1997). The earlier approaches to treating antiso-
cial personality disorder and psychopathy took place largely in high secure hospitals
(where 25% met criteria for legally defined psychopathic disorder). As with the treat-
ment of personality disorder more generally, psychoanalytic approaches to treatment
were most prevalent (Cordess & Cox, 1998).
Partially informed by developments in the ‘what works’ criminological literature,
cognitive behavioural approaches have gained in prominence. For instance, in the
Dangerous and Severe Personality Disorder (DSPD) service (see Section 2.7) that
provides interventions for highly psychopathic men, a range of interventions are
available including dialectical behaviour therapy, schema-focused therapy, cognitive
analytic therapy, violence reduction programmes, and so on (Home Office, 2005a).
These interventions await evaluation.
2.6.3 Psychosocial interventions
In the development of treatments for personality disorders the therapeutic community

and its various developments have played an important role. The Henderson Hospital
28
was a specialist inpatient unit specifically developed to treat personality disorder in

the NHS (Rapoport, 1960). The therapeutic community movement had a significant
impact on mental healthcare in the mid to late 20th century (Lees et al., 2003) with
parallel developments in the prison service (Grendon Underwood; Snell, 1962) and
drug services. However, in the healthcare field there has been a recent move away
from this area in part because of high costs in the absence of convincing evidence for
efficacy.
Interventions for offenders

Although the evidence of efficacy in intervening for those with antisocial personal-
ity disorder is slight, there is an important parallel criminological literature that is
considered in this guideline. The literature on interventions to reduce offending
behaviour is greater in volume and quality than that for antisocial personality
disorder per se and so is potentially important to this guideline. However, this liter-
ature (reviewed in Chapter 7) has two limitations: it does not make an antisocial
personality disorder diagnosis a necessary condition of entry to the studies and the
outcome criteria are usually restricted to the presence or absence of re-offending.
While these studies are clearly relevant to those with antisocial personality disorder
(given that those in prison are likely to have this disorder), developing a guideline
on the basis of this evidence is clearly not straightforward and is discussed further
in succeeding sections.
2.7 THE DANGEROUS AND SEVERE PERSONALITY

DISORDER INITIATIVE
A recent and important national initiative is the Dangerous and Severe Personality
Disorder (DSPD) Programme (Home Office & Department of Health, 2002). DSPD
is an umbrella term, grouping together people with a severe personality disorder
where there is a significant risk of serious harm to others. It is likely that many people
with DSPD also fulfil criteria for antisocial personality disorder. For the purpose of
DSPD assessments, the criteria for ‘severe personality disorder’ are defined as follows
(Home Office, 2005a):
● a PCL-R score of 30 or above (or the Psychopathy Checklist-Screening Version
[PCL-SV] equivalent); or
● a PCL-R score of 25-29 (or the PCL-SV equivalent) plus at least one DSM-IV
personality disorder diagnosis other than antisocial personality disorder; or
● two or more DSM-IV personality disorder diagnoses.
The DSPD programme in England and Wales provides treatment for approxi-
mately 300 men in high security with about half in prisons and half in high secure
hospitals. Treatment consists mainly of cognitive behavioural programmes delivered
in group and individual settings and aimed at risk reduction. Anticipated length of
stay is between 3 and 5 years. It is therefore too early for a definitive evaluation
particularly because many individuals will be transferred to other secure facilities at
the end of treatment rather than being discharged to the community. The programme
29
incorporates extensive evaluation including a minimum dataset collated centrally

for all men in the high secure prison and hospital places as well as independent
evaluation of assessment, treatment outcome, and organisational and management
arrangements.
While the extent of service planning and public funds committed to this group is
significant, these services are restricted to a very small proportion of the population
so they are likely to have only a minimal impact on the very large numbers of people
with antisocial personality disorder, the majority of whom are in prison or in the
community.
2.8 THE ORGANISATION AND COORDINATION

OF TREATMENT AND CARE
The organisation and coordination of care is the subject of a separate chapter

(Chapter 4). The purpose of this section is to outline the key issues to be considered
in that chapter and how they will be integrated through the guideline. Most people
with antisocial personality disorder receive the majority of their care outside the
health service. They make demands on educational, social care and housing serv-
ices and, as result of their offending, on the criminal justice system. The effective
delivery of a healthcare intervention for antisocial personality disorder will there-
fore require an acknowledgement and understanding of the wider system as a mini-
mum, but for those individuals with complex needs it will also require effective
coordination of care across multiple agencies. This can be very demanding work,
especially when it is carried out in the community with the most troublesome
offenders and those who provoke the most anxiety, and has led to the development
of specific coordination systems such as the Multi-Agency Public Protection
Arrangements (MAPPA) panels (Home Office, 2005c), which coordinate multi-
agency care from mental health, social services and the criminal justice system.
Whichever system of coordination is chosen it is likely that a number of agencies
(in addition to mental health services) will need to play a part if the cycle of contin-
uing adversity is to be broken. Successful interventions for those with antisocial
personality disorder may require these interventions to be multimodal and across
most of the life span.
However, such complex interventions are expensive and not widespread around
the country, and it is therefore inevitable that some people who need treatment may
not receive it. They may also not receive treatment because psychiatric teams still
reject those who behave antisocially and because people with antisocial personality
disorder are often reluctant to engage in treatment. Their callous and unemotional
response to vulnerability may extend to themselves: they may see their own needs as
signs of weakness and treat them with contempt, and by extension, treat caregivers
with contempt.
One of the key conceptual issues that affects services for antisocial personality
disorder and psychopathy is the persistent belief that these disorders exist in isolation,
30
especially in relation to Axis I disorders. Some of the homicides committed by the

mentally ill that have been the subject of inquiries occurred because men with both
antisocial personality disorder and a psychotic disorder were turned away on the
grounds that they ‘only’ had a personality disorder and therefore were not mentally
ill. Even in very experienced services, professionals find it hard to accept that severe
personality disorders and severe mental illness not only coexist, but are very likely to
coexist (Blackburn et al., 2003). Thus if services are set up as either ‘personality
disorder services’ or ‘mental illness services’, the most risky, treatment averse people
will not be identified.
2.9 ASSESSMENT
Much of the focus on the assessment of people with antisocial personality disorder
has focused on the assessment of risk, in particular risk to others. (This is the specific
focus of Chapter 6 and will not be discussed in detail here.) However, people with
antisocial personality disorder often have complex needs, which in turn require
complex assessment often from a multi-agency and multi-professional perspective
and would include not only risk but mental state (because of the high level of comor-
bid mental disorders in people with antisocial personality disorder presenting to
services), drug and alcohol misuse (the latter has a strong association with the risk
of violent or offending behaviour), physical health needs, social and housing needs
and also the needs of family members, in particular children. The Department of
Health document, Personality Disorder: No Longer a Diagnosis of Exclusion
(2003), is clear that personality disorder should no longer be a reason for being
denied treatment; however without effective assessment an effective treatment plan
is not likely to be put in place.
The issue of assessment raises questions about the structure and purpose of
assessment of antisocial personality disorder at different levels of the healthcare
system. In many mental disorders there is an increasing emphasis on a stepped
care approach to treatment (NCCMH, 2005a) and although the evidence base is
limited it is possible that this will be considered an appropriate way forward for
antisocial personality disorder (this is discussed further in Chapter 4). However
whichever model is chosen it is likely that the focus on assessment and interven-
tion, at least in healthcare, will vary across the healthcare system. One approach
that may be helpful is to consider people with antisocial personality disorder
presenting to primary care as having ‘problems’; those presenting to secondary
care as having ‘symptoms’; and those presenting to tertiary care to having either
‘complex problems’ or requiring a forensic assessment. For this approach to be
effective within the stepped care model, practitioners at different levels would
require guidance on: (a) recognition of the disorder and its implications regarding
the presenting problem; (b) how to respond to this in an appropriate manner; and (c)
under which circumstances a referral to another tier is indicated. (See Chapter 4 for
further discussion.)
31
2.10 ETHICAL CONSIDERATIONS IN ANTISOCIAL

PERSONALITY DISORDER
2.10.1 Introduction
So far this chapter has focused on the professional or societal approach to person-
ality disorder, but antisocial personality disorder also raises key ethical issues. In
relation to antisocial personality disorder and psychopathy, a key conceptual ques-
tion is whether they are disorders at all. The debate is complicated by the fact that
philosophers have used the concept of the psychopath as a medical entity to explore
issues of moral reasoning and responsibility (Murphy, 1972; Duff, 1977; Malatesti,
2006); while, at the same time, a debate has continued in psychology and psychia-
try whether psychopaths (and indeed, people with antisocial personality disorder)
are properly the subject of medical discourse at all, precisely because of the impli-
cations for criminal responsibility. Much of the current research has been used to
address this debate: therefore, if there is a biological basis for antisocial personality
disorder and psychopathy, then, it is argued, it is a disorder, which needs treatment,
or at least intervention.
This debate is too large to review in any depth here, but there are three related
aspects that may be useful to consider. First, debaters in this area need to beware of
conceptual slippage: ‘antisocial behaviour’ is not the same as criminality or violence
or antisocial personality disorder or psychopathy. Much more is known about the
brains of those who behave in cruel and unusual ways than was known 10 years ago
and those findings cannot explain why people in general choose to behave antiso-
cially. Second, neural/genetic findings can only contribute to an understanding of the
causes of any behaviour. All human behaviours are complex, and involve higher level
thinking about motives, beliefs, attributions, both in the actor and those affected by
him/her. It seems very probable that genetic vulnerability interacts with environment
to produce a neural matrix that contributes causally to socially significant rule break-
ing: but it is only a contribution, and not a total explanation. Third, researchers and
healthcare policy makers need to understand that because the problems posed by
people with antisocial personality disorder and psychopathy are social ones, there will
have to be a social/political dimension to the work that is undertaken. This often
seems alien to many healthcare professionals and scientists who see biosciences as
politically and morally neutral. But people who behave antisocially, for whatever
reason, generate negative attitudes in the rest of their social group, and those attitudes
will not fade away quickly. Even if it could be demonstrated that all social behaviour
is caused by failure of inhibition to the amygdala, this is unlikely to change public
attitudes to the perpetrators. Another problem is that most social groups accept some
degree of antisocial rule breaking as normal and tolerable. Therefore researchers will
only ever be able to work with highly selected samples of social rule breakers: ones
identified by the fact that they have crossed a certain social threshold and invited what
Strawson calls ‘participant reactive attitudes’ (Strawson, 1968). Therefore care needs
to be taken about what extrapolations are made from the research, and the social atti-
tudes that may be challenged by research findings.
32
These issues have influenced the position taken in this guideline: that not all crimi-
nal rule breaking is evidence of mental disorder, but that some of the most egregious
types of criminality, such as extremes of violence towards the vulnerable, do reflect fail-
ures in the capacity to relate to others that amount to a disorder. A useful concept here is
that of the eighth amendment to the US constitution: a state of mind that results in ‘cruel
and unusual’ behaviour is, on the balance of probabilities, a disordered mind.
2.10.2 Treatability
The notion of ‘treatment’ for antisocial personality disorder and psychopathy also
raises a number of ethical issues, principally the assumption that it is a disorder that
is amenable to intervention. As Adshead (2002) has pointed out, the ‘treatability’ of
any disorder relies on a number of factors, not all of which are to do with the individ-
ual patient. A key issue in the treatment of antisocial personality disorder and
psychopathy is the test of therapeutic outcome: how will the practitioner know if
treatment has been successful? In the past, treatments have focused on either people
feeling better or behaving better, and practitioners have sometimes assumed that one
implies the other. Treatments also have within them an implied theoretical model
about what is ‘wrong’ with the individual concerned: but if the model is wrong, then
the treatment may be ineffective, even if it is well thought out and well delivered.
The conceptual problem referred to above dominates debates about treatment and
treatment outcomes. However, many researchers and clinicians would argue that
people with antisocial personality disorder are in states of mind in which other people
are seen as either predator or prey, and that they are therefore justified in acting
cruelly towards them. Interventions could then be geared to enabling individuals to
examine their own states of mind more, understand the minds of others, and have an
investment in behaving more pro-socially. Interventions could include psychological
treatment, social and vocational rehabilitation, education and medication. They may
also include long-term social support (not least because social isolation is a potent
risk factor for violence in high-risk individuals).
There is evidence that some of these interventions can change behaviour, at least for
some people, through developing a more pro-social state of mind. The ethical issues then
turn on resource allocation. Most ethical arguments about healthcare resources are utili-
tarian in nature: what will bring about the most good for the greatest number? For exam-
ple, in relation to the DSPD programme, the argument has been that the provision of
services will prevent severe harm. Whether this is true is the subject of current research
enquiry, ideally including a comparison with a treatment/intervention-as-usual group,
although the ethical problems here may be insuperable (Farrington & Welsh, 2006).
2.10.3 Issues of coercion in relation to antisocial personality disorder
It is a general principle of bioethics that respect for the autonomy of patients is para-
mount, and a general principle of law that everyone has control over his/her own body
33
and any treatment interventions that are offered. Under the new Mental Capacity Act
(HMSO, 2005), any person with capacity can refuse treatment, even if this is to
his/her own detriment.
The only people with capacity who cannot refuse treatment, and can have treat-
ment forced upon them, are those with mental disorders who pose a risk to themselves
or others. The ‘or’ is crucial here; most libertarian philosophical arguments (Saks,
2003) would contend that forced medical treatment is only justified to improve a
person’s own health and safety, and that the insult to dignity is outweighed by the
prevention of serious harm.
It has long been a matter of debate about the extent to which societies should
coerce people into treatment that is not of benefit to them directly, especially where
the ‘treatment’ is aimed at reducing risk to others, regardless of what the individual
wants. This is at least partly because when this is done, the person is treated merely
as a means to an end, not as an end in themselves, and this type of insult to human
dignity is morally unacceptable.
Mental health professionals often argue that they are not doing this in two ways.
First, they will argue that the patients are benefiting, even if indirectly; at least they
are benefiting from not being allowed to harm others. A problem with this argument
is that is could be seen as discriminatory—generally competent citizens are allowed
to choose whether they do harm or not, and take the consequences. It should be
remembered that the current Mental Health Act (HMSO, 2007), even with its amend-
ments, allows for the detention and forced treatment of people with full capacity.
Second, it is argued that people who are a risk to others have lost some of their
claims to full exercise of autonomy. Given that they are likely to be deprived of their
liberty if they harm others, there may be little insult to dignity in offering treatment
while they are detained. This argument of course applies only to prisoners, and those
who have harmed others already; it cannot apply to those who are detained on the
chance that they may offend.
This presents significant challenges for mental health professionals. There may
need to be a distinction made between legal coercion and therapeutic persuasion. It is
very unlikely that all antisocial patients can be coerced into pro-social thinking or
behaviour. This raises important issues of balance between the rights of individuals to
have liberty restrained or treatment imposed against the rights of a community to be
protected from potential harm.
2.10.4 Risk assessment
Central to the issue of coerced treatment is the problem of identifying those who pres-
ent a risk (this is discussed more fully in Chapter 6). The main concerns about justice
arise from issues of consent and accuracy. To detain a person because they are a risk
to others may be entirely justified if it is true. Those assessing risk therefore need to
be certain that their methods of risk assessment are accurate and also fairly used. For
example, risk assessment needs to look at both resilience and protective factors that
might reduce risk, not just those factors that make risk more likely. It will not be just
34
to detain someone (especially if it is indefinite) if all positive factors have not been
considered. It will be especially unjust if the main reason for detention is professional
anxiety alone. Currently there is considerable controversy about the best methods of
undertaking individual risk assessment with some arguing that actuarially-based
methods such as the Violence Risk Appraisal Guide (VRAG) or PCL-R have reason-
able properties to enable prediction of violence at the individual level (for example,
Campbell et al., 2007); while others argue that is it is not appropriate to use such
measures to routinely inform clinical decisions (for example, Cooke et al., 2007; Hart
et al., 2007).
There is also the problem that the most at-risk people are those who are not
identified for risk assessment; that is, that in relation to mental illness at least, the
thing that makes people risky is their unpredictability. As several authors have noted,
one would have to detain a large number of individuals who had done nothing, to
prevent one homicide (for example, Dolan & Doyle, 2000).What this means is that
society accepts that some degree of violence will occur, but possibly not if it is
committed by those with mental disorders.
There is another aspect to risk assessment that has not received much attention. If
risk assessment is a healthcare intervention, and part of the overall medical manage-
ment of forensic patients, then it could be argued that it needs the patient’s consent.
This is particularly so given that it is a medical intervention (like a lumbar puncture)
that could have serious side effects for the patient. Under the Mental Capacity Act
(HMSO, 2005), it may be possible for capacitous patients to refuse risk assessment,
and it might then be argued that it would be unlawful to carry out a risk assessment
without consent.
Healthcare professionals often resist the use of violence risk assessment on the
grounds that it is stigmatising to the individual or conflicts with good clinical care.
Yet assessment of risk also implies assessment of safety; for every individual identi-
fied as presenting a high risk, the same process will indicate that others present a low
risk and should be managed accordingly. For every patient identified as having a high
score on instruments such as the PCL-R, many others will be shown to have a low
score. There is sometimes a genuine conflict of values between patient autonomy and
the safety of others. The conflict should not be ignored but managed by the use of
evidence-based diagnostic and risk assessments that are transparent and open to
challenge. Traditional methods of assessment often meet neither standard.
2.10.5 The ethics of public protection
A real ethical debate exists abut the extent to which a range of healthcare professionals
should be involved in public protection. On the one hand, there are those who take the
view that their knowledge and expertise in assessing risk imposes a duty on them to
act on that knowledge to assist in public protection from a small number of risky
individuals with mental disorders (especially antisocial personality disorder and
psychopathy). On the other hand, there are those who take the view that their primary
ethical duty is to ‘make the care of the patient their first concern’ (General Medical
35
Council, 2006), and who argue that acting in ways that reduce risk but cause patients
distress or anxiety violates their ethical duty and identity as doctors.
This debate has taken on an extra significance with the passing of the Criminal
Justice Act (HMSO, 2003), which requires psychiatric expert testimony before
passing sentences for public protection (that is, sentences that are longer than usual,
or may lead to indefinite detention). In these circumstances, psychiatrists are provid-
ing testimony that, it might be argued, causes harm to the defendant, at least, from the
defendant’s viewpoint. In the UK, the psychiatrist treating the patient may also be the
one who is invited to give an expert opinion about the patient’s risk on the grounds
that they know the patient best. If the treating psychiatrist takes the view that they
have a duty to public safety, which overrides the duty to the patient’s interests, then
the patient may find that the doctor in whom they have confided is using those
confidences against them in the wider interest of the public good.
The key ethical tension here is arguably about deceit, not a clash of duties. The
anxiety is that in the pursuit of public protection, mental health professionals will
mislead patients into thinking that the patient’s interests are their first concern. If
mental health professionals inform forensic patients that their first duty is to public
safety, and that therefore they will disclose private medical information when neces-
sary even if the patient refuses to give consent, then this is a transparent procedure,
and the patient can decide how then to conduct themselves. In a medico-legal context,
where the assessing doctor has no prior therapeutic relationship with the patient, then
arguably the relationship between them is not a traditional medical one, and the
transaction is straightforward and there is no clash of ethical duties (Appelbaum,
1997). The ethical concern is about honesty: that a healthcare professional will allow
the patient or defendant to think that they will protect their interests against those of
third parties, when they have no intention of doing so.
A possible ethical and legal solution to the tension is for the mental health
professional to gain informed consent for both risk assessments and medico-legal
interviews, in which they clearly advise patients/defendants of the purpose of the
interview, the use to which the material will be put and who will be informed of
the outcome. Given the potentially negative outcomes of these assessments for the
patient/defendant, it could be argued that existing law on informed consent and
refusal of treatment requires that patients/defendants be informed that they need not
answer the doctor’s questions. There remains an anxiety that even with this type of
warning against self-incrimination, patients/defendants may not understand that the
assessor is not in a traditional beneficent role. From a therapeutic point of view,
complete transparency about the potential conflict of duties is likely to promote trust
and a collaborative attitude in the patient/defendant.
The Royal College of Psychiatrists’ Scoping Group on Expert Testimony has
submitted a report (Royal College of Psychiatrists, 2008a) advising experts of the
distinction between testimony given for therapeutic purposes and testimony given for
public protection purposes. The American Academy of Psychiatry and the Law
(2005) has issued ethical guidelines to its members, which state that no psychiatrist
should give expert testimony on a patient they are treating. In the UK, there are
particularly difficult conflicts around Mental Health Tribunal evidence, where the
36
responsible medical officer (RMO) gives professional evidence as to the clinical care
of the patient, and expert forensic evidence about the nature of the risk they pose to
others. This tension arises because the Mental Health Act (HMSO, 2007) assumes
that patients with mental disorders lack capacity to make good quality decisions, and
that psychiatrists are therefore justified in doing what they think best, including in
relation to public safety. However, since most patients (especially those with antiso-
cial personality disorder) have full legal capacity, and can exercise autonomy, the
RMO’s position may no longer be justified, and their role in public protection
becomes primary. It is for this reason that some detained patients see their lawyers as
being the only people who represent their interests in a trustworthy way (Sarkar &
Adshead, 2005).
2.10.6 Ethical issues and children
Children are considered in this guideline as the focus of preventative interventions

(see Chapter 5).
The prevention of antisocial personality disorder

Here the aim is to alter the course of a childhood disorder such as conduct disorder
and thereby potentially prevent the development of antisocial personality disorder in
adult life. The work on preventative interventions is the focus of Chapter 5 and their
efficacy will not be discussed in any further detail here. The ethical problem is that
interventions that might prevent the development of antisocial personality disorder
may contravene the ethical principles of beneficence and justice for all patients.
All ethical dilemmas involve a clash of values or ethical principles; some dilem-
mas are especially concerning because there is no painless outcome and even doing
the right thing may lead to a moral loss (for example, the issue of coerced treatment).
Interventions to prevent antisocial personality disorder will be justified in terms of
beneficial consequences in the future: no (or reduced) antisocial personality disorder,
and thus the prevention of harm to others, costs to society and antisocial individuals.
There is no question that the outcomes look very attractive as benefits. The question
is: at what cost to human dignity and justice will these benefits come? Will the ends
justify the harms done in the process? And most importantly in ethical decision
making: who gets to decide?
Given that genetic vulnerabilities may increase a child’s chance of developing
conduct disorder, especially if they are raised in an abusive environment, if nothing
can be done to help the child, there may be little point in identifying them. Indeed,
their chance of failure may be increased because the environment around them may
be even more rejecting and suspicious of them.
The provision of services to an at-risk child, however identified, will depend on
the resources allocated for this. It is easier to change a child’s environment than it is
to change their genes. For example, if we take the genetically vulnerable child iden-
tified above, one intervention might be to place them in a secure home where they will
not be maltreated. This may mean: (a) taking the child away from the parents before
37
there is any chance of maltreatment; and (b) investing funds to provide the secure
base for the child’s development. These measures could reduce the amount of conduct
disorder (and therefore possibly antisocial personality disorder), but may be costly in
terms of justice and resources. Again, resource allocation is a matter of values: there
is no good reason not to do everything that can be done to prevent the maltreatment
of children except that society may decide to spend the money in another way. The
key ethical issue here is the resource allocation of funds for research and interventions
with at-risk children. Identifying individuals at risk may be less useful in the long
term than trying to reduce maltreatment of the child overall.
38
Methods used to develop this guideline
3 METHODS USED TO DEVELOP

THIS GUIDELINE
3.1 OVERVIEW
The development of this guideline drew upon methods outlined by NICE (2006a). A
team of healthcare professionals, lay representatives and technical experts known as
the Guideline Development Group (GDG), with support from the NCCMH staff,
undertook the development of a patient-centred, evidence-based guideline. There are
six basic steps in the process of developing a guideline:
● Define the scope, which sets the parameters of the guideline and provides a focus
and steer for the development work.
● Define clinical questions considered important for practitioners and service users.
● Develop criteria for evidence searching and search for evidence.
● Design validated protocols for systematic review and apply to evidence recovered
by search.
● Synthesise and (meta-) analyse data retrieved, guided by the clinical questions,
and produce evidence profiles and summaries.
● Answer clinical questions with evidence-based recommendations for clinical
practice.
The clinical practice recommendations made by the GDG are therefore derived
from the most up-to-date and robust evidence base for the clinical and cost effec-
tiveness of the treatments and services used in the treatment, management and
prevention of antisocial personality disorder. In addition, to ensure a service user
and carer focus, the concerns of service users and carers regarding health and social
care have been highlighted and addressed by recommendations agreed by the whole
GDG.
3.2 THE SCOPE
Guideline topics are selected by the Department of Health and the Welsh Assembly
Government, which identify the main areas to be covered by the guideline in a
specific remit (see NICE, 2006a). The NCCMH developed a scope for the guideline
based on the remit.
The purpose of the scope is to:
● provide an overview of what the guideline will include and exclude
● identify the key aspects of care that must be included
● set the boundaries of the development work and provide a clear framework to
enable work to stay within the priorities agreed by NICE and the National
39
Collaborating Centre and the remit from the Department of Health/Welsh

Assembly Government
● inform the development of the clinical questions and search strategy
● inform professionals and the public about expected content of the guideline
● keep the guideline to a reasonable size to ensure that its development can be
carried out within the allocated period.
The draft scope was subject to consultation with registered stakeholders over a
4-week period. During the consultation period, the scope was posted on the NICE
website (www.nice.org.uk). Comments were invited from stakeholder organisations
and Guideline Review Panel (GRP). Further information about the GRP can also be
found on the NICE website. The NCCMH and NICE reviewed the scope in light of
comments received, and the revised scope was signed off by the GRP.
3.3 THE GUIDELINE DEVELOPMENT GROUP
The GDG consisted of a representative for service users, and professionals from
psychiatry, forensic psychiatry, clinical psychology, forensic psychology, social
work, general practice, nursing, general practice in prison, Child and Adolescent
Mental Health Services (CAMHS), the Ministry of Justice and the Probation
Service. The carer perspective was provided by a carer special adviser. The guide-
line development process was supported by staff from the NCCMH, who under-
took the clinical and health economics literature searches, reviewed and presented
the evidence to the GDG, managed the process, and contributed to drafting the
guideline.
3.3.1 Guideline Development Group meetings
Fifteen GDG meetings were held between March 2007 and October 2008. During
each day-long GDG meeting, in a plenary session, clinical questions and clinical and
economic evidence were reviewed and assessed, and recommendations formulated.
At each meeting, all GDG members declared any potential conflicts of interest, and
any concerns voiced by the representative for service users were routinely discussed
as part of a standing agenda.
3.3.2 Topic groups
The GDG divided its workload along clinically relevant lines to simplify the guide-
line development process, and GDG members formed smaller topic groups to
undertake guideline work in that area of clinical practice. Topic group 1 covered
questions relating to the organisation and experience of care; topic group 2 covered
risk assessment and management; topic group 3 covered early intervention for
children; and topic group 4 covered interventions for offending behaviour. These
40
groups were designed to efficiently manage the large volume of evidence appraisal
before presenting it to the GDG as a whole. Each topic group was chaired by a
GDG member with expert knowledge of the topic area (one of the healthcare
professionals). Topic groups refined the clinical questions, refined the clinical
definitions of treatment interventions, reviewed and prepared the evidence with
the systematic reviewer before presenting it to the GDG as a whole and helped the
GDG to identify further expertise in the topic. Topic group leaders reported the
status of the group’s work as part of the standing agenda. They also introduced
and led the GDG discussion of the evidence review for that topic and assisted the
GDG Chair in drafting the section of the guideline relevant to the work of each
topic group.
3.3.3 Service users and carers
Individuals with direct experience of services gave an integral service-user focus to

the GDG and the guideline. The GDG included a representative for the interests of
service users. He contributed as a full GDG member in writing the clinical questions,
helping to ensure that the evidence addressed the views and preferences of service
users, highlighting sensitive issues and terminology relevant to the guideline, and
bringing service user research to the attention of the GDG. In drafting the guideline,
he contributed to writing the guideline’s introduction and identified recommendations
from the service user and carer perspective. In addition, the carer perspective was
sought from a carer special adviser.
3.3.4 Special advisers
Special advisers, who had specific expertise in one or more aspects of treatment and
management relevant to the guideline, assisted the GDG, commenting on specific
aspects of the developing guideline and making presentations to the GDG. Appendix
3 lists those who agreed to act as special advisers.
3.3.5 National and international experts
National and international experts in the area under review were identified through
the literature search and through the experience of the GDG members. These
experts were contacted to recommend unpublished or soon-to-be published studies
in order to ensure up-to-date evidence was included in the development of the
guideline. They informed the group about completed trials at the pre-publication
stage, systematic reviews in the process of being published, studies relating to the
cost effectiveness of treatment and trial data if the GDG could be provided with full
access to the complete trial report. Appendix 6 lists researchers who were
contacted.
41
3.4 CLINICAL QUESTIONS
Clinical questions were used to guide the identification and interrogation of the
evidence base relevant to the topic of the guideline. Before the first GDG meeting, an
analytic framework (see Appendix 7) was prepared by NCCMH staff based on the
scope and an overview of existing guidelines, and discussed with the guideline Chair.
The framework was used to provide a structure from which the clinical questions
were drafted. Both the analytic framework and the draft clinical questions were then
discussed by the GDG at the first few meetings and amended as necessary. Where
appropriate, the framework and questions were refined once the evidence had been
searched and, where necessary, sub-questions were generated. Questions submitted
by stakeholders were also discussed by the GDG and the rationale for not including
questions was recorded in the minutes. The final list of clinical questions can be found
in Appendix 7.
For questions about interventions, the PICO (patient, intervention, comparison and
outcome) framework was used. This structured approach divides each question into
four components: the patients (the population under study), the interventions (what is
being done), the comparisons (other main treatment options) and the outcomes (the
measures of how effective the interventions have been) (see Text Box 1).
Questions relating to assessment do not involve an intervention designed to treat
a particular condition, therefore the PICO framework was not used. Rather, the ques-
tions were designed to pick up key issues specifically relevant to assessment instru-
ments, for example their accuracy, reliability, and how they relate to clinical practice.
Text Box 1: Features of a well-formulated question on effectiveness

intervention – the PICO guide
Patients/population Which patients or population of patients are we inter-

ested in? How can they be best described? Are there
subgroups that need to be considered?
Intervention Which intervention, treatment or approach should be
used?
Comparison What is/are the main alternative/s to compare with the
intervention?
Outcome What is really important for the patient? Which
outcomes should be considered: intermediate or short-
term measures; mortality; morbidity and treatment
complications; rates of relapse; late morbidity and read-
mission; return to work, physical and social functioning
and other measures such as quality of life; general
health status; costs?
42
In some situations, the prognosis of a particular condition is of fundamental impor-

tance, over and above its general significance in relation to specific interventions.
Areas where this is particularly likely to occur relate to assessment of risk, for exam-
ple in terms of behaviour modification or screening and early intervention. In addition,
questions related to issues of service delivery are occasionally specified in the remit
from the Department of Health /Welsh Assembly Government. In these cases, appro-
priate clinical questions were developed to be clear and concise.
To help facilitate the literature review, a note was made of the best study design
type to answer each question. There are four main types of clinical question of rele-
vance to NICE guidelines. These are listed in Text Box 2. For each type of question,
the best primary study design varies, where ‘best’ is interpreted as ‘least likely to give
misleading answers to the question’.
However, in all cases, a well-conducted systematic review of the appropriate type
of study is likely to always yield a better answer than a single study.
Deciding on the best design type to answer a specific clinical or public health
question does not mean that studies of different design types addressing the same
question were discarded.
3.5 SYSTEMATIC CLINICAL LITERATURE REVIEW
The aim of the clinical literature review was to identify and synthesise systematically
the relevant evidence from the literature in order to answer the specific clinical ques-
tions developed by the GDG. Thus, clinical practice recommendations are evidence-
based, where possible, and, if evidence is not available, informal consensus methods
are used (see Section 3.5.7) and the need for future research is specified.
Text Box 2: Best study design to answer each type of question
Type of question Best primary study design

Effectiveness or other impact of RCT; other studies that may be considered
an intervention in the absence of an RCT are the following:
internally/externally controlled before and
after trial, interrupted time-series
Accuracy of information Comparing the information against
(for example, risk factor, a valid gold standard in a randomised
test, prediction rule) trial or inception cohort study
Rates (of disease, patient Cohort, registry, cross-sectional study
experience, rare side effects)
Costs Naturalistic prospective cost study
43
3.5.1 Methodology
A stepwise, hierarchical approach was taken to locating and presenting evidence to

the GDG. The NCCMH developed this process based on methods set out in The
Guidelines Manual (NICE, 2006a) and after considering recommendations from a
range of other sources. These included:
● Clinical Policy and Practice Program of the New South Wales Department of
Health (Australia)
● Clinical Evidence online
● The Cochrane Collaboration
● Grading of Recommendations: Assessment, Development and Evaluation
(GRADE) Working Group
● New Zealand Guidelines Group
● NHS Centre for Reviews and Dissemination
● Oxford Centre for Evidence-Based Medicine
● Oxford Systematic Review Development Programme
● Scottish Intercollegiate Guidelines Network (SIGN)
● United States Agency for Healthcare Research and Quality.
3.5.2 The review process
After the scope was finalised, a more extensive search for systematic reviews and
published guidelines was undertaken. Existing NICE guidelines were updated where
necessary. Other relevant guidelines were assessed for quality using the AGREE
instrument (AGREE Collaboration, 2003). The evidence base underlying high-quality
existing guidelines was utilised and updated as appropriate (further information about
this process can be found in The Guidelines Manual (NICE, 2006a).
At this point, the review team, in conjunction with the GDG, developed an
evidence map that detailed all comparisons necessary to answer the clinical questions.
The initial approach taken to locating primary-level studies depended on the type of
clinical question and availability of evidence. For example, questions on experience
of care are best addressed by qualitative studies whereas questions regarding inter-
ventions are best addressed by RCTs (see below for further details on search strate-
gies for different topics).
The GDG decided which questions were best addressed by good practice based on
expert opinion, which questions were likely to have a good evidence base and which
questions were likely to have little or no directly relevant evidence. Recommendations
based on good practice were developed by informal consensus within the GDG. For
questions with a good evidence base, the review process depended on the type of key
question (see below). For questions that were unlikely to have a good evidence base, a
brief descriptive review was initially undertaken by a member of the GDG.
Searches for evidence were updated between 6 and 8 weeks before the guideline
consultation. After this point, studies were included only if they were judged by the GDG
to be exceptional (for example, the evidence was likely to change a recommendation).
44
The search process for questions concerning interventions

For questions related to interventions, the initial evidence base was formed from well-
conducted RCTs that addressed at least one of the clinical questions. Although there
are a number of difficulties with the use of RCTs in the evaluation of interventions in
mental health, the RCT remains the most important method for establishing treatment
efficacy (this is discussed in more detail in appropriate clinical evidence chapters). For
other clinical questions, searches were for the appropriate study design (see above).
All searches were based on the standard mental health related bibliographic data-
bases (EMBASE, MEDLINE, PsycINFO, Cochrane Library, CENTRAL and C2-
SPECTR) for all trials potentially relevant to the guideline.
In addition, where material relating to interventions was unlikely to be found in
mainstream medical databases, an attempt was made to identify and search other
topic specific databases, including NCJRS, IBSS and FEDRIP.
After the initial search results were scanned liberally to exclude irrelevant papers,
the review team used a purpose-built ‘study information’ database to manage both the
included and the excluded studies (eligibility criteria were developed after consulta-
tion with the GDG). For questions without good quality evidence (after the initial
search), a decision was made by the GDG about whether to (a) repeat the search using
subject-specific databases (for example, CINAHL, AMED, SIGLE or PILOTS), (b)
conduct a new search for lower levels of evidence, or (c) adopt a consensus process
(see Section 3.5.7). Future guidelines will be able to update and extend the usable
evidence base starting from the evidence collected, synthesised and analysed for this
guideline.
In addition, searches were made of the reference lists of all eligible systematic
reviews and included studies, as well as the list of evidence submitted by stakehold-
ers. Known experts in the field (see Appendix 5), based both on the references iden-
tified in early steps and on advice from GDG members, were sent letters requesting
relevant studies that were in the process of being published1. In addition, the tables of
contents of appropriate journals were periodically checked for relevant studies.
The search process for questions concerning the organisation and experiences of care
For questions related to the organisation and experiences of care, the search process
was the same as described above, except that the evidence base was formed from
qualitative studies. In situations where it was not possible to identify a substantial
body of appropriately designed studies that directly addressed each clinical question,
a consensus process was adopted (see Section 3.5.7).
The search process for questions of assessment

For questions related to assessment, the search process was the same as described
above, except that the initial evidence base was formed from studies with the most
1Unpublished full trial reports were also accepted where sufficient information was available to judge eligi-
bility and quality (see section on unpublished evidence).
45
appropriate and reliable design to answer the particular question. That is, for ques-
tions about assessment, the initial search was for cross-sectional studies. In situations
where it was not possible to identify a substantial body of appropriately designed
studies that directly addressed each clinical question, a consensus process was
adopted (see Section 3.5.7).
Search strategies
Search strategies developed by the review team consisted of a combination of subject
heading and free-text phrases. Specific strategies were developed for the guideline
topic and, where necessary, for each clinical question. In addition, the review team
used filters developed for systematic reviews, RCTs and other appropriate research
designs (Appendix 8).
Study selection
All primary-level studies included after the first scan of citations were acquired in full
and re-evaluated for eligibility at the time they were being entered into the study
information database. Appendix 8 lists the standard inclusion and exclusion criteria.
More specific eligibility criteria were developed for each clinical question and are
described in the relevant clinical evidence chapters. Eligible systematic reviews and
primary-level studies were critically appraised for methodological quality (see
Appendix 9 and Appendix 10). The eligibility of each study was confirmed by at least
one member of the appropriate topic group.
For some clinical questions, it was necessary to prioritise the evidence with
respect to the UK context (that is, external validity). To make this process explicit, the
topic groups took into account the following factors when assessing the evidence:
● participant factors (for example, gender, age and ethnicity)
● provider factors (for example, model fidelity, the conditions under which the inter-
vention was performed and the availability of experienced staff to undertake the
procedure)
● cultural factors (for example, differences in standard care and differences in the
welfare system).
It was the responsibility of each topic group to decide which prioritisation factors
were relevant to each clinical question in light of the UK context and then decide how
they should modify their recommendations.
Unpublished evidence
The GDG used a number of criteria when deciding whether or not to accept unpub-
lished data. First, the evidence must have been accompanied by a trial report contain-
ing sufficient detail to properly assess the quality of the data. Second, the evidence
must have been submitted with the understanding that data from the study and a
summary of the study’s characteristics would be published in the full guideline.
Therefore, the GDG did not accept evidence submitted as commercial in confidence.
However, the GDG recognised that unpublished evidence submitted by investigators
might later be retracted by those investigators if the inclusion of such data would
jeopardise publication of their research.
46
3.5.3 Data extraction
Study characteristics and outcome data were extracted from all eligible studies, which
met the minimum quality criteria, using a bespoke database and Review Manager
4.2.10 (Nordic Cochrane Centre, 2006) (see Appendix 9).
In most circumstances, for a given outcome (continuous and dichotomous), where
more than 50% of the number randomised to any group were lost to follow up, the
data were excluded from the analysis (except for the outcome ‘leaving the study early
for any reason’, in which case, the denominator was the number randomised). Where
possible, dichotomous efficacy outcomes were calculated on an intention-to-treat
basis (that is, a ‘once-randomised-always-analyse’ basis). Where there was good
evidence that those participants who ceased to engage in the study were likely to have
an unfavourable outcome, early withdrawals were included in both the numerator and
denominator. Adverse effects were entered into Review Manager as reported by the
study authors because it was usually not possible to determine whether early with-
drawals had an unfavourable outcome. Where there was limited data for a particular
review, the 50% rule was not applied. In these circumstances the evidence was down-
graded due to the risk of bias.
Where some of the studies failed to report standard deviations (for a continuous
outcome), and where an estimate of the variance could not be computed from other
reported data or obtained from the study author, the following approach was taken2:
1. When the number of studies with missing standard deviations was small and
when the total number of studies was large, the average standard deviation was
imputed (calculated from the included studies that used the same outcome). In
this case, the appropriateness of the imputation was made by comparing the stan-
dardised mean differences (SMDs) of those trials that had reported standard devi-
ations against the hypothetical SMDs of the same trials based on the imputed
standard deviations. If they converged, the meta-analytical results were consid-
ered to be reliable.
2. When the number of studies with missing standard deviations was large or when
the total number of studies was small, standard deviations were taken from a
previous systematic review (where available), because the small sample size may
allow unexpected deviation due to chance. In this case, the results were consid-
ered to be less reliable.
The meta-analysis of survival data, such as time to any mood episode, was based
on log hazard ratios and standard errors. Since individual patient data were not avail-
able in included studies, hazard ratios and standard errors calculated from a Cox
proportional hazard model were extracted. Where necessary, standard errors were
calculated from confidence intervals or p-value according to standard formulae (for
example, Cochrane Reviewers’ Handbook 4.2.2.). Data were summarised using the
generic inverse variance method using Review Manager 4.2.10 (Nordic Cochrane
Centre, 2006).
2Based on the approach suggested by Furukawa and colleagues (2006).
47
Consultation with another reviewer or members of the GDG was used to overcome
difficulties with coding. Data from studies included in existing systematic reviews
were extracted independently by one reviewer and cross-checked with the existing data
set. Where possible, two independent reviewers extracted data from new studies.
Where double data extraction was not possible, data extracted by one reviewer was
checked by the second reviewer. Disagreements were resolved with discussion. Where
consensus could not be reached, a third reviewer or GDG members resolved the
disagreement. Masked assessment (that is, blind to the journal from which the article
comes, the authors, the institution and the magnitude of the effect) was not used since
it is unclear that doing so reduces bias (Jadad et al., 1996; Berlin, 2001).
3.5.4 Synthesising the evidence
Where possible, meta-analysis was used to synthesise the evidence using Review
Manager 4.2.10 (Nordic Cochrane Centre, 2006). If necessary, reanalyses of the data
or sub-analyses were used to answer clinical questions not addressed in the original
studies or reviews.
Dichotomous outcomes were analysed as relative risks (RR) with the associated
95% CI (for an example, see Figure 1). A relative risk (also called a risk ratio) is the
ratio of the treatment event rate to the control event rate. An RR of 1 indicates no
difference between treatment and control. In Figure 1, the overall RR of 0.73 indi-
cates that the event rate (that is, non-remission rate) associated with intervention A is
about three quarters of that with the control intervention or, in other words, the rela-
tive risk reduction is 27%.
The CI shows with 95% certainty the range within which the true treatment effect
should lie and can be used to determine statistical significance. If the CI does not
cross the ‘line of no effect’, the effect is statistically significant.
Continuous outcomes were analysed as weighted mean differences (WMD), or as
an SMD when different measures were used in different studies to estimate the same
underlying effect (for an example, see Figure 2). If provided, intention-to-treat data,
using a method such as ‘last observation carried forward’, were preferred over data
from completers.
Figure 1: Example of a forest plot displaying dichotomous data

Review: NCCMH clinical guideline review (Example)
Comparison: 01 Intervention A compared to a control group
Outcome: 01 Number of people who did not show remission
Study Intervention A Control RR (fixed) Weight RR (fixed)
or sub-category n/N n/N 95% CI % 95% CI
01 Intervention A vs. control
Griffiths1994 13/23 27/28 38.79 0.59 [0.41, 0.84]
Lee1986 11/15 14/15 22.30 0.79 [0.56, 1.10]
Treasure1994 21/28 24/27 38.92 0.84 [0.66, 1.09]
Subtotal (95% CI) 45/66 65/70 100.00 0.73 [0.61, 0.88]
Test for heterogeneity: Chi2 = 2.83, df = 2 (P = 0.24), I2 = 29.3%
Test for overall effect: Z = 3.37 (P = 0.0007)
0.2 0.5 1 2 5
Favours intervention Favours control
48
Figure 2: Example of a forest plot displaying continuous data
Review: NCCMH clinical guideline review (Example)
Comparison: 01 Intervention A compared to a control group
Outcome: 03 Mean frequency (endpoint)
Study Intervention A Control SMD (fixed) Weight SMD (fixed)
or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI
01 Intervention A vs. control
Freeman1988 32 1.30(3.40) 20 3.70(3.60) 25.91 -0.68 [-1.25, -0.10]
Griffiths1994 20 1.25(1.45) 22 4.14(2.21) 17.83 -1.50 [-2.20, -0.81]
Lee1986 14 3.70(4.00) 14 10.10(17.50) 15.08 -0.49 [-1.24, 0.26]
Treasure1994 28 44.23(27.04) 24 61.40(24.97) 27.28 -0.65 [-1.21, -0.09]
Wolf1992 15 5.30(5.10) 11 7.10(4.60) 13.90 -0.36 [-1.14, 0.43]
Subtotal (95% CI) 109 91 100.00 -0.74 [-1.04, -0.45]
2 2
Test for heterogeneity: Chi = 6.13, df = 4 (P = 0.19), I = 34.8%
Test for overall effect: Z = 4.98 (P < 0.00001)
–4 –2 0 2 4
Favours intervention Favours control
To check for consistency between studies, both the I2 test of heterogeneity and a
visual inspection of the forest plots were used. The I2 statistic describes the propor-
tion of total variation in study estimates that is due to heterogeneity (Higgins &
Thompson, 2002). The I2 statistic was interpreted in the follow way:
● ⬎50%: notable heterogeneity (an attempt was made to explain the variation, for
example outliers were removed from the analysis or sub-analyses were conducted
to examine the possibility of moderators. If studies with heterogeneous results
were found to be comparable, a random-effects model was used to summarise the
results [DerSimonian & Laird, 1986]. In the random-effects analysis, heterogene-
ity is accounted for both in the width of CIs and in the estimate of the treatment
effect. With decreasing heterogeneity the random-effects approach moves asymp-
totically towards a fixed-effects model).
● 30 to 50%: moderate heterogeneity (both the chi-squared test of heterogeneity and
a visual inspection of the forest plot were used to decide between a fixed and
random-effects model).
● ⬍30%: mild heterogeneity (a fixed-effects model was used to synthesise the results).
To explore the possibility that the results entered into each meta-analysis suffered
from publication bias, data from included studies were entered, where there was suffi-
cient data, into a funnel plot. Asymmetry of the plot was taken to indicate possible
publication bias and investigated further.
An estimate of the proportion of eligible data that were missing (because some
studies did not include all relevant outcomes) was calculated for each analysis.
The Number Needed to Treat for Benefit (NNTB) or the Number Needed to Treat
for Harm (NNTH) was reported for each outcome where the baseline risk (that is,
control group event rate) was similar across studies. In addition, NNTs calculated at
follow-up were only reported where the length of follow-up was similar across stud-
ies. When the length of follow-up or baseline risk varies (especially with low risk),
the NNT is a poor summary of the treatment effect (Deeks, 2002).
Included/excluded studies tables, generated automatically from the study data-
base, were used to summarise general information about each study (see Appendix 9).
Where meta-analysis was not appropriate and/or possible, the reported results from
each primary-level study were also presented in the included studies table (and
included, where appropriate, in a narrative review).
49
3.5.5 Presenting the data to the GDG
Study characteristics tables and, where appropriate, forest plots generated with
Review Manager (Nordic Cochrane Centre, 2006) were presented to the GDG in
order to prepare a GRADE evidence profile table for each review and to develop
recommendations.
GRADE profile tables

A GRADE evidence profile was used to summarise both the quality of the evidence
and the results of the evidence synthesis (see Table 1 for an example of an evidence
profile). For each outcome, quality may be reduced depending on the following
factors:
● study design (randomised trial, observational study, or any other evidence)
● limitations (based on the quality of individual studies; see Appendix 10 for the
quality checklists)
● inconsistency (see Section 3.5.4 for how consistency was measured)
● indirectness (that is, how closely the outcome measures, interventions and partic-
ipants match those of interest)
● imprecision (based on the confidence interval around the effect size).
For observational studies, the quality may be increased if there is a large effect,
plausible confounding would have changed the effect, or there is evidence of a dose-
response gradient (details would be provided under the ‘other considerations’
column). Each evidence profile also included a summary of the findings: number of
patients included in each group, an estimate of the magnitude of the effect and the
overall quality of the evidence for each outcome.
The quality of the evidence was based on the quality assessment components
(study design, limitations to study quality, consistency, directness and any other
considerations) and graded using the following definitions:
● High ⫽ Further research is very unlikely to change our confidence in the estimate
of the effect.
● Moderate ⫽ Further research is likely to have an important impact on our confi-
dence in the estimate of the effect and may change the estimate.
● Low ⫽ Further research is very likely to have an important impact on our confi-
dence in the estimate of the effect and is likely to change the estimate.
● Very low ⫽ Any estimate of effect is very uncertain.
For further information about the process and the rationale of producing an
evidence profile table see GRADE (GRADE Working Group, 2004).
Forest plots
Each forest plot displayed the effect size and CI for each study as well as the overall
summary statistic. The graphs were organised so that the display of data in the area
to the left of the ‘line of no effect’ indicated a ‘favourable’ outcome for the treatment
in question.
50
Table 1: Example of GRADE evidence profile
Quality assessment Summary of findings
No. of patients Effect
No. of Design Limitations Inconsistency Indirectness Imprecision Other Intervention Control Relative Absolute Quality
studies consider- (95% CI)
ations
Outcome 1
6 randomised no serious no serious no serious serious1 none 8/191 7/150 RR 0.94 0 fewer per 100 丣丣丣
trial limitations inconsistency indirectness (0.39 to 2.23) (from 3 fewer to MODERATE
6 more)
Outcome 2
6 randomised no serious no serious no serious serious2 none 55/236 63/196 RR 0.44 18 fewer per 100 丣丣丣
trial limitations inconsistency indirectness (0.21 to 0.94)3 (from 2 fewer to MODERATE
25 fewer)
Outcome 3
3 randomised no serious no serious no serious no serious none 83 81 – MD −1.51 丣丣丣丣

trial limitations inconsistency indirectness imprecision (-3.81 to 0.8) HIGH
Outcome 4
3 randomised no serious no serious no serious serious4 none 88 93 – SMD −0.26 丣丣丣

trial limitations inconsistency indirectness (−0.56 to 0.03) MODERATE
Outcome 5
4 randomised no serious no serious no serious serious4 none 109 114 – SMD −0.13 丣丣丣
trial limitations inconsistency indirectness (−0.6 to 0.34) MODERATE
1Theupper confidence limit includes an effect that, if it were real, would represent a benefit that, given the downsides, would still be worth it.
2Thelower confidence limit crosses a threshold below which, given the downsides of the intervention, one would not recommend the intervention.
51
3Random-effects model.
495% CI crosses the minimal importance difference threshold.
3.5.6 Forming the clinical summaries and recommendations
Once the GRADE profile tables relating to a particular clinical question were
completed, summary tables incorporating important information from the GRADE
profiles were developed (these tables are presented in the evidence chapters). Finally,
the systematic reviewer in conjunction with the topic group lead produced a clinical
evidence summary.
Once the GRADE profiles and clinical summaries were finalised and agreed
by the GDG, the associated recommendations were drafted, taking into account
the trade-off between the benefits and downsides of treatment as well as other
important factors. These included economic considerations, values of the devel-
opment group and society and the GDG’s awareness of practical issues (Eccles,
et al., 1998).
In addition, when recommendations were completed, the GDG identified areas
that would benefit from future research and developed research recommendations.
These were based on areas identified by the systematic literature search indicating a
lack of evidence. Further criteria included: the potential importance of the data gained
to inform updates of the guideline, what is known about planned research or research
currently in progress, feasibility of the study within the timescale of the update, and
the likely sources of available funding.
3.5.7 Methods used to answer a clinical question in the absence

of appropriately designed, high-quality research
In the absence of appropriately designed, high-quality research, or where the GDG

were of the opinion (on the basis of previous searches or their knowledge of the liter-
ature) that there were unlikely to be such evidence, an informal consensus process
was adopted. This process focused on those questions that the GDG considered a
priority.
Informal consensus
The starting point for the process of informal consensus was that a member of the
topic group identified, with help from the systematic reviewer, a narrative review that
most directly addressed the clinical question. Where this was not possible, a brief
review of the recent literature was initiated.
This existing narrative review or new review was used as a basis for beginning an
iterative process to identify lower levels of evidence relevant to the clinical question
and to lead to written statements for the guideline. The process involved a number of
steps:
1. A description of what is known about the issues concerning the clinical question
was written by one of the topic group members.
2. Evidence from the existing review or new review was then presented in narrative
form to the GDG and further comments were sought about the evidence and its
perceived relevance to the clinical question.
52
3. Based on the feedback from the GDG, additional information was sought and
added to the information collected. This may include studies that did not directly
address the clinical question but were thought to contain relevant data.
4. If, during the course of preparing the report, a significant body of primary-level
studies (of appropriate design to answer the question) were identified, a full
systematic review was done.
5. At this time, subject possibly to further reviews of the evidence, a series of state-
ments that directly addressed the clinical question were developed.
6. Following this, on occasions and as deemed appropriate by the development
group, the report was then sent to appointed experts outside the GDG for peer
review and comment. The information from this process was then fed back to the
GDG for further discussion of the statements.
7. Recommendations were then developed and could also be sent for further exter-
nal peer review.
8. After this final stage of comment, the statements and recommendations were
again reviewed and agreed upon by the GDG.
3.6 HEALTH ECONOMICS METHODS
The aim of health economics is to contribute to the guideline’s development by

providing evidence on the cost effectiveness of healthcare interventions for people
with antisocial personality disorder and associated symptoms and behaviours as well
as interventions for children and adolescents for the prevention of antisocial person-
ality disorder. This was achieved by:
● systematic literature review of existing economic evidence
● economic modelling in areas with potentially major resource implications where
economic evidence was lacking or was considered inadequate to inform decisions.
The rest of this section describes the methods adopted in the systematic literature
review of economic studies. Methods employed in de novo economic modelling are
described in the respective economic sections of the guideline.
3.6.1 Search strategy
For the systematic review of economic evidence the standard mental health related
bibliographic databases (EMBASE, MEDLINE, CINAHL and PsycINFO) were
searched. For these databases, a health economics search filter adapted from the
Centre for Reviews and Dissemination at the University of York was used in combi-
nation with a general search strategy for antisocial personality disorder, offending
behaviour and the antisocial personality disorder construct (see Chapter 7 for expla-
nation of this term). Additional searches were performed in specific health econom-
ics databases (NHS EED, OHE HEED), as well as in the HTA database. For the HTA
and NHS EED databases, general search strategies for the population groups of inter-
est were used. OHE HEED was searched using a shorter, database-specific strategy.
53
Initial searches were performed in January 2007. The searches were updated regu-
larly, with the final search conducted 6 weeks before the consultation period. Details
on the search strategies adopted for the systematic review of economic evidence are
provided in Appendix 11.
In parallel with searches of electronic databases, reference lists of eligible studies
and relevant reviews were searched by hand. Studies included in the clinical evidence
review were also screened for economic evidence.
In addition to searches for economic evidence, literature on health-related quality
of life (HRQoL) of people with antisocial personality disorder and related symptoms
and behaviours was systematically searched to identify studies reporting appropriate
utility weights that could be utilised in a cost-utility analysis.
The systematic search for economic evidence resulted in more than 20,000 refer-
ences in total. Publications that were clearly not relevant to the topic (that is, did not
provide any information on the economics of antisocial personality disorder and
related symptoms and behaviours) were excluded first. The abstracts of all poten-
tially relevant publications (108 papers) were then assessed against a set of inclusion
criteria by the health economist. Full texts of all potentially eligible studies (includ-
ing those for which relevance/eligibility was not clear from the abstract) were
obtained. Studies that did not meet the inclusion criteria, were duplicates, were
secondary publications of one study, or had been updated in more recent publica-
tions were subsequently excluded. Finally, 32 studies that provided information on
the economics of antisocial personality disorder and related symptoms and behav-
iour were selected. Of these, 15 were cost-of-illness studies or studies that reported
data on healthcare resource use and intangible costs associated with the populations
covered in the guideline, and 17 studies were economic evaluations of interventions
for the management or prevention of antisocial personality disorder, offending
behaviour and related conditions. All economic evaluations eligible for inclusion in
the systematic review of economic literature were critically appraised according to
the checklists used by the British Medical Journal to assist referees in appraising full
and partial economic analyses (Drummond & Jefferson, 1996) (see Appendix 12).
3.6.2 Inclusion criteria
The following inclusion criteria were applied to select studies identified by the
economic searches for further analysis:
● No restriction was placed on language or publication status of the papers.
● Studies published from 1996 onwards were included. This date restriction was
imposed in order to obtain data relevant to current healthcare settings and costs.
● Only studies from Organisation for Economic Co-operation and Development
countries were included, as the aim of the review was to identify economic infor-
mation transferable to the UK context.
● Selection criteria regarding types of clinical conditions and population groups as
well as minimum required periods of follow-up were identical to that determined
for the clinical literature review.
54
● Studies were included provided that sufficient details regarding methods and
results were available to enable the methodological quality of the study to be
assessed, and provided that the study’s data and results were extractable. Poster
presentations of abstracts were excluded.
● Full economic evaluations that compared two or more relevant options and
considered both costs and consequences (that is, cost–consequence analyses, cost-
effectiveness analyses, cost–utility analyses or cost–benefit analyses) as well as
partial economic evaluations (that is, costing analyses) were included in the
systematic review; non-comparative studies were not considered for review.
3.6.3 Data extraction
Data were extracted by the health economists using a standard economic data extrac-
tion form (see Appendix 13).
3.6.4 Presentation of economic evidence
The economic evidence identified by the health economic systematic review is

summarised in the respective chapters of the guideline, following presentation of the
clinical evidence. The characteristics and results of all economic studies included in
the review are provided in the form of evidence tables in Appendix 14. Results of
additional economic modelling undertaken alongside the guideline development
process are also presented in the respective sections of evidence chapters.
3.7 STAKEHOLDER CONTRIBUTIONS
Professionals, service users, and companies have contributed to and commented on

the guideline at key stages in its development. Stakeholders for this guideline include:
● service user/carer stakeholders: the national service user and carer organisations
that represent people whose care is described in this guideline
● professional stakeholders: the national organisations that represent healthcare
professionals who are providing services to service users
● commercial stakeholders: the companies that manufacture medicines used in the
treatment of antisocial personality disorder
● Primary Care Trusts
● Department of Health and Welsh Assembly Government.
Stakeholders have been involved in the guideline’s development at the following
points:
● commenting on the initial scope of the guideline and attending a briefing meeting
held by NICE
● contributing possible clinical questions and lists of evidence to the GDG
● commenting on the draft of the guideline.
55
3.8 VALIDATION OF THE GUIDELINE
Registered stakeholders had an opportunity to comment on the draft guideline, which

was posted on the NICE website during the consultation period. Following the
consultation, all comments from stakeholders and others were responded to, and the
guideline updated as appropriate. The GRP also reviewed the guideline and checked
that stakeholders’ comments had been addressed.
Following the consultation period, the GDG finalised the recommendations and
the NCCMH produced the final documents. These were then submitted to NICE.
NICE then formally approved the guideline and issued its guidance to the NHS in
England and Wales.
56
Organisation and experience of care
4 ORGANISATION AND EXPERIENCE

OF CARE
4.1 INTRODUCTION
As described in Chapter 2, antisocial personality disorder is multi-faceted and

impinges on the lives of people with the disorder, their families and wider society in
many different ways. This chapter focuses on a number of aspects of the care of
people with antisocial personality disorder, including the organisation and delivery of
care, the experience of staff who are responsible for providing care, and the experi-
ences of service users and carers of the provision of services.
4.2 ORGANISATION AND DELIVERY OF CARE
4.2.1 History of services for antisocial personality disorder
The history of the development of services for antisocial personality disorder is

closely linked to changes in the criminal justice system and attempts by the judicial
system to understand and deal with extreme criminal behaviour (Ferguson & Tyrer,
2000). Clinicians have been enlisted to help understand those crimes in which behav-
iour, though abnormal, was not part of any recognised mental illness. Terms such as
‘moral insanity’ (Prichard, 1835) and ‘psychopathic inferiority’ (Koch, 1891) were
developed. It was Kraepelin (1905) who created the classification ‘personality disorder’,
and specifically ‘psychopathic personality’. This was further refined by Henderson
(1939), Cleckley (1941) and McCord and McCord (1956), whose views were influ-
ential in shaping later classifications of sociopathy (DSM-I; APA, 1952), antisocial
personality disorder (DSM-II; APA, 1968, onwards), dissocial personality disorder
(ICD) and psychopathy (Hare, 1980).
However, little in the way of specific treatments emerged beyond the care of a few
individuals who had committed the most extreme acts and would find themselves in
long-term high security environments. In 1959, the term psychopathic disorder was
incorporated into the UK Mental Health Act (HMSO, 1959), which made it possible
for patients with psychopathic disorder to be admitted to hospital compulsorily.
Psychopathic disorder was defined as ‘a persistent disorder of mind (whether or not
accompanied by sub-normality of intelligence) which resulted in abnormally aggres-
sive or seriously irresponsible conduct on the part of the patients, and require or are
susceptible to medical treatment’ (HMSO, 1959). While the definition presented
some problems when used in routine clinical care, the 1959 Act did explicitly intro-
duce the idea that people had a potentially treatable disorder. This change in the Act
was a product of a generally increased optimism about the role of psychiatry in the
57
immediate post-war period, in particular the success in treating the psychological

problems associated with what would be now called post-traumatic stress disorder
(PTSD) (the Northfield experiment; Harrison, 2002), the increasing influence of
psychoanalytic ideas in mainstream psychiatry and the focus on the social environ-
ment both as a potential cause of mental disorder and as a means of treating it (Clark,
1965). Specific initiatives such as the Henderson Hospital, established in 1947,
focused explicitly on the treatment of personality disorder. The Henderson was the
first therapeutic community in the UK and the therapeutic community movement that
developed from it had a profound effect on British psychiatry with many hospitals
developing modifications of the approach (Clark, 1965). The movement was also part
of a wider recognition of the role of social factors in mental disorders, including the
work of George Brown and colleagues on institutionalisation (Wing & Brown, 1970)
and the development of the academic discipline of social psychiatry. At the same time
there began a very significant expansion in the availability of psychological interven-
tions with some, particularly psychoanalytic therapies, focusing on personality prob-
lems (Kernberg, 1984).
The influence of the therapeutic community model was not limited to healthcare
interventions for mental disorders. Two other important trends in the development of
the model emerged, namely the modifications of the therapeutic model for use in the
treatment of offenders and the treatment of drug and alcohol misuse. The offender
programmes began in prisons, with Grendon Underwood being the most notable of
these in the UK (Snell, 1962); the model has also been developed in a number of
countries, such as the US in the 1960s and 1970s (Lees et al., 2003). Many treatment
units for drug and alcohol problems in both the healthcare and independent sectors
developed a therapeutic community approach where the focus on treatment was as
much on the person’s interpersonal difficulties as on the specific drug or alcohol prob-
lem (Rawlings & Yates, 2001).
In recent years there have been significant changes with therapeutic communities
falling out of favour, and treatment of antisocial personality disorder taking place in
hospital settings; more generally there has been more of a focus on the treatment of
borderline personality disorder (Lees et al., 2003). In addition, the high cost and
limited evidence for the efficacy of these units has resulted in some closing, includ-
ing the Henderson. In drug and alcohol services the therapeutic community movement
has remained stronger, with renewed interest in prison-based treatment programmes,
but there have been modifications with a stronger focus on drug misuse and an
emphasis on supporting post-inpatient or residential treatment through extended
community follow-up (for example, Wexler et al., 1999).
The therapeutic community movement, although having an impact on the models
underpinning general adult psychiatry, has had little influence on the direct provision
of care for people with antisocial personality disorder. As can be seen from the recent
Department of Health document Personality Disorder: No Longer a Diagnosis of
Exclusion (2003), very few people with personality disorder (including those with
antisocial personality disorder) were treated in general services and in many cases
they were actively excluded, not just for the treatment of their antisocial problems but
also for comorbid mental health problems. Recent research suggests that this is still
58
the case even in services with a specific focus on personality disorder (Crawford
et al., 2007). The last 20 years have also seen a significant expansion in the provision
of forensic psychiatric services, which, it might reasonably be expected, would have
played a significant role in the treatment of people with antisocial personality disorder.
However, there are few specialist services that focus specifically on antisocial person-
ality disorder (one dedicated service is Arnold Lodge in the East Midlands).
Although the initial interest in the development of the concept of psychopathy
came from the study of individuals who had committed very serious offences, there
has been little development in specialist treatment units for these people. A number
of the high security hospitals have developed specialist personality disorder units, but
it has proved difficult to manage these services successfully and they have, on occasion,
been the subject of considerable public concern (for example, Fallon et al., 1999). A
recent development in the UK has been the development of specialist services for
people with dangerous and severe personality disorder (DSPD) (Home Office,
2005a). The programme aims to support ‘public protection through the development
of pilot treatment services for dangerous offenders whose offending is linked to
severe personality disorder’, but also to improve their mental health outcomes and to
understand more fully the treatments that work for this group (Home Office, 2005a).
Where community services exist specifically for the treatment of antisocial
personality disorder, these are most well developed within the criminal justice
system, in which people with antisocial personality disorder have historically
formed a significant proportion of those attending probation services. In recent
years there has been a move away from a case work model in probation services
(based on the social work model) to one that focuses more explicitly on reducing
re-offending (Vanstone, 2000). This has led to the development of a number of
community treatments that draw heavily on cognitive behavioural techniques (for
example, Hollin, 1999).
4.2.2 The current provision of care
The current provision of care for people with antisocial personality disorder is the
responsibility of a number of organisations, principally those in the criminal justice
system, but with significant input for specific populations from specialist forensic
mental health services. All mental health services, in particular drug and alcohol serv-
ices, and to a lesser extent general mental health services, provide support and care
for people with antisocial personality disorder, but this is usually not for the treatment
of the disorder itself but for comorbid conditions. The needs of people with antisocial
personality disorder who present in primary care are even less well recognised.
Primary care
As with all forms of mental disorder, the majority of people with personality disorder
who require treatment are cared for within primary care services (Department of
Health, 2003). Approximately a quarter of attendees to GP practices fulfil diagnosis
for personality disorder, often presenting with comorbid common mental health
59
problems (Moran et al., 2000). Of these, 5.2% will have an ICD-10/DSM-IV diagnosis
of dissocial or antisocial personality disorder (Moran et al., 2000). It is only those
who experience the most significant distress who are referred to specialist mental
health services, with there being a much greater likelihood of contact with the
criminal justice system (Eastern Specialised Mental Health Commissioning Group
[ESMHCG], 2005). Given the recognition of the potential treatability of comorbid
mental disorders and the role that drug and alcohol misuse may play in exacerbating
antisocial behaviour, greater awareness needs to be developed to ensure that early
support and interventions are in place to identify and treat people who have a diagnosis
of personality disorder in primary care.
Secondary care
Many people with personality disorder, including those with antisocial personality
disorder, are treated in general secondary mental health services, although the majority
of these are in receipt of interventions for comorbid Axis I disorders and not
treatments for antisocial personality disorder (Goodwin & Hamilton, 2003). Similarly
drug and alcohol services will also treat significant numbers of people with antisocial
personality disorder (Bowden-Jones et al., 2004). Acute inpatient units involved in
the treatment of patients with personality disorder (predominantly borderline person-
ality disorder) have a specific but limited role in managing crisis, including escalation
of risk to self or others (Department of Health, 2003). The ways in which people with
personality disorder, including those with antisocial personality disorder, have been
managed by mental health services are complicated, and service users have often
been treated at the margins through A&E departments, inpatient wards and on the
caseloads of the community psychiatric staff who may not have the required special-
ist skills and time (ESMHCG, 2005).
In 2002 only 17% of trusts in England provided dedicated personality disorder
services; 40% provided some level of service; 28% provided no identified service;
and 32% returned no data (Department of Health, 2003). The report also found a
disparity of therapeutic approaches and mode of service delivery (Department of
Health, 2003). The most common therapies included psychodynamic psychotherapy,
CBT, dialectical behaviour therapy or cognitive analytic therapy, delivered on both an
outpatient and day patient basis (Department of Health, 2003).
There is also very limited specialist residential treatment within the NHS, with
four units in the UK that are run as therapeutic communities: the Therapeutic
Community Service (previously known as Webb House, Crewe), Main House, Cassel
Hospital and the Francis Dixon Lodge (Department of Health, 2003). These predom-
inantly provide services for people with borderline personality disorder.
Crawford and Rutter (2007) reviewed 11 dedicated community-based personality
disorder pilot services funded by the Department of Health in England. The evalua-
tion found that most services were designed primarily for people with personality
disorder who had some motivation to change (Crawford & Rutter, 2007). Several had
formal exclusion criteria, most commonly the presence of a psychotic illness, use of
medication or uncontrolled substance misuse, significant learning difficulties and
history of significant violence or aggressive behaviour. Staff at most of the pilot sites
60
reported that they worked predominantly with people with cluster B and C personality
disorders, the most common diagnosis being borderline personality disorder. In
contrast, most services reported that they did not work with people whose foremost
diagnosis was antisocial personality disorder (Crawford et al., 2007). While several
services had links with the criminal justice system and were able to offer advice and
support to those working with people with antisocial personality disorder, concerns
about risk to others meant that most services excluded people with the diagnosis
(Crawford & Rutter, 2007). Service providers were concerned that people with
antisocial personality disorder might be unresponsive to psychological treatment;
however providers were prepared to work with people with other forms of personality
disorder where there was limited evidence for effective treatment (Crawford & Rutter,
2007). Referrers of patients to these specialist pilot services were frustrated that
people with antisocial personality disorder could not be referred to their local person-
ality disorder services.
Nevertheless despite the rather negative findings about antisocial personality
disorder, Crawford & Rutter (2007) found there was a broad agreement about the
basic parameters for providing services to people with personality disorder. They
stated that services should:
● be delivered over a relatively long period
● work flexibly with service users while ensuring the service they provide is consis-
tent and reliable
● have the capacity to deliver more than one intervention of varying intensity to suit
those with different levels of motivation
● deliver social as well as psychological interventions
● have the ability to ensure that service users are given time to prepare for leaving
the service
● combine direct service provision with support for colleagues working in other
settings aimed at increasing their capacity to work with people with personality
disorder and decrease social exclusion
● ensure that staff work closely together and receive regular supervision.
Tertiary care
Forensic mental health services care for mentally ill people who need a degree of
security and have shown challenging or risky behaviour that is beyond the capacity of
general psychiatric services to effectively manage. Forensic services fall into three
categories: low security services, which tend to be based near general psychiatric
wards in NHS hospitals; medium security services, which often operate regionally
and usually consist of locked wards with a greater number and a wider range of staff;
and high security services, which are provided by the three special hospitals
(Ashworth, Broadmoor and Rampton), which have much greater levels of security
and care for people who pose an immediate and serious risk to others. In addition,
new services are developing to meet the needs of high-risk offenders in the community
with mental disorders, for example Resettle, formally known as Community Risk
Assessment and Case Management Service (CRACMS), in northwest England
(Ministry of Justice, 2007).
61
The roles of forensic services are to provide treatment interventions, address

offending behaviour and reduce the level risk associated with antisocial behaviour
(Department of Health, 2003). A crucial component of forensic services is to develop
a working partnership with criminal justice agencies including multi-agency public
protection panels (MAPPPs; Department of Health, 2003). Despite this broad brief,
which clearly applies to those with antisocial personality disorder, a survey by the
Eastern Specialised Mental Health Commissioning Group (ESMHCG) (2005) found
that across medium and low security services in the East Midlands, admission criteria
often excluded those with a primary diagnosis of personality disorder, unless patients
were transferred from high security services. The ESMHCG suggested that clear
protocols and guidance on admission criteria were needed (ESMHCG, 2006). In addi-
tion the ESMHCG suggested that forensic teams provide the following, specifically
in relation to personality disorder: (a) consultation, liaison and case management
advice; (b) advice to courts, including court reports; (c) preliminary examination
under the proposed mental health legislation; and (d) links with prison mental health
care services.
Dangerous and Severe Personality Disorder (DSPD) programme

DSPD services have two distinct functions: to carry out structured clinical assessments
that seek to establish whether an individual meets DSPD criteria and, for those who
meet DSPD criteria, to provide treatment that addresses mental need and risk (Home
Office, 2005a). Development of treatment services are the responsibility of the individ-
ual units, however certain principles and goals are common to the treatment programmes
in all the units, including: (a) treatments that address offending behaviour through the
reduction of risk by targeting criminogenic factors and meeting mental health needs; (b)
evidence-based treatment models that are subject to rigorous validation and evaluation;
(c) individualised treatment plans that are flexible with regular progress reviews using
the Care Programme Approach; and (d) involvement of prisoners/patients in treatment
planning, encouraging them to share ownership of treatment outcomes where treatment
goals should be open and transparent (Home Office, 2005a).
Medium security and community services

For admission to forensic medium security DSPD units, patients must have a diagno-
sis of personality disorder that would meet the criteria for detention under mental
health legislation; the patient must present a serious physical or psychological risk to
others or potential risk of a degree that requires admission to a medium security serv-
ice; and there must be a link between the personality disorder and high risk that can
be clinically justified, where the treatment needs of the patient are best met in a secure
NHS setting (Home Office, 2005b). Admission to community services will require a
diagnosis of personality disorder, a history of serious risk to others associated with
the disorder, and an assessment that the risk can be better managed through the inter-
vention of these services (Home Office, 2005b). For admission to a specialist hostel-
supported housing project, the individual must have a primary diagnosis of a
personality disorder, a history of serious offending against others, or a significant
potential for future harm to others; and all other local provisions should have agreed
62
clinically not to meet the person’s needs, where the hostel-supported housing project
is able to do so (Home Office, 2005b).
High security units

Individuals are considered to meet the criteria for admission to DSPD high security
services if they are assessed as being more likely than not to re-offend, resulting in
serious physical or psychological harm from which the victim would find it difficult
or impossible to recover. The risk of re-offending must also be linked to the presence
of a severe personality disorder. Structured clinical assessments are required to be
carried out to make an overall decision regarding whether an individual meets DSPD
criteria (Home Office, 2005a). Referrals to a high security DSPD unit can be consid-
ered for any person who might meet the DSPD criteria; the consent of an individual
is not required for a referral to be made, however, the individual must be informed of
their referral before it can be accepted (Home Office, 2005a). HMP Whitemoor began
admitting prisoners to a converted wing of the prison in September 2000 (Home
Office, 2005a). Additional units have been purposely built at three other sites: the
Westgate Unit at HMP Frankland, the Peaks Unit at Rampton Hospital and the
Paddock Centre at Broadmoor (Home Office, 2005a).
Safety and security in DSPD units

The planning and delivery guidance for DSPD units (Home Office, 2005a; 2005b)
states that patients and prisoners are expected to test boundaries and to identify and
exploit weaknesses that may exist in the operational system or in working relation-
ships on the unit. This could cause a significant risk to the health and safety of staff
(Home Office, 2005a; 2005b). The Home Office (2005a; 2005b) made the following
recommendations to maintain a secure and safe working environment in DSPD units:
● operational policies and procedures should be open, clear and regularly reviewed
● systems should be in place to record and analyse information on security incidents
and ‘near-misses’
● staff on units should have access to regular supervision and support services
● staff absences and patterns of recruitment and retention should be actively
managed and monitored
● units should operate on an integrated, multi-disciplinary basis
● a management culture of trust and openness should be developed with an emphasis
on positive exploration of errors and learning from mistakes.
Provision of care in prisons

The mental health needs of prisoners have long been recognised as being substantial
but also, in many cases, poorly met (HM Inspectorate of Prisons, 2007). Although
there are services for people with personality disorder, the provision of mental health
services in prison is limited and therefore often strictly prioritised, with the main
concerns being acute mental health problems, acute suicide risk and pre-discharge
needs assessment (ESMHCG, 2005).
One solution to this problem is for prisoners with a diagnosis of personality
disorder to be included within specification for mental health service provision in
63
prison (ESMHCG, 2005), although this would include perhaps 50% of the prison
population (Singleton et al., 1998). In many prisons the most likely intervention
will be a cognitive and behavioural skills programme such as Reasoning and
Rehabilitation, but this is focused on the offending behaviour and not the antisocial
personality disorder (see Chapter 7). It should also be remembered that the high
psychiatric comorbidity of this population may also require specific mental health
interventions. While recognising the constraints and the significant work that has
taken place to establish effective mental health services in prison, the ESMHCG
recommended that the service specification for prison mental health services should
recognise the needs of people with personality disorder (including antisocial
personality disorder) in prisons, that a realistic plan is developed to improve serv-
ice provision in prison, and that discharge arrangements are effective, including
ensuring that, where appropriate, prisoners who are discharged have follow-up
arrangements with mental health services in addition to suitable accommodation
and registration with a GP.
Multi-agency working
The focus of this guideline is on healthcare services, but effective care of people with
antisocial personality disorder is not possible without close working links with other
services, in particular the criminal justice system. Indeed for the majority of people
in the community with antisocial personality disorder who are in contact with serv-
ices, the primary care will come from the probation service through individual care
work and offender management programmes. It is therefore vital that strong links
exist across these organisations to ensure effective care is provided. In addition to
health and the criminal justice system, housing, adult education and the voluntary
sector services will be required.
4.2.3 Summary of the organisation and delivery of care
There have been significant advances in the organisation, development and delivery
of care for people with antisocial personality disorder. However, it is questionable
whether many of the more substantial investments, particularly offender-based inter-
ventions in prisons and the community (such as Reasoning and Rehabilitation) have
impacted on the care for people with antisocial personality disorder in healthcare
settings in a significant way.
Yet the vast majority of people with antisocial personality disorder remain in the
community and have significant psychiatric morbidity and associated social and inter-
personal difficulties. While these individuals are often not treatment seeking, effec-
tive interventions for comorbid problems are nevertheless available (see Chapter 7).
Comorbid alcohol and drug misuse could have a significant impact not just on the
individual’s health and well being but also on that of their families and the wider
community. It is important, therefore, that services have clear pathways that allow for
the effective engagement of people with antisocial personality disorder in general
mental health and substance misuse services and that specialist services meet their
64
comorbid needs. While the majority of people with antisocial personality disorder are
engaged with primary care, and to a lesser extent with secondary services, and only a
small number move through to specialist services, the latter nevertheless have a
significant role in providing ongoing support and training to those working in primary
and secondary care services. The provision of effective care pathways and the relevant
roles of individuals in supporting these should be clear.
Services should therefore consider the establishment of personality disorder
networks. These networks should have a significant role in training, including the
training of specialist and general mental health professionals and staff working in
the criminal justice system. These networks should also provide support and may
provide a resource for specialist support and supervision. They may also have some
role in coordinating pathways within various health services.
4.2.4 Recommendations
Assessment
4.2.4.1 When assessing a person with possible antisocial personality disorder,
healthcare professionals in secondary and forensic mental health services
should conduct a full assessment of:
● antisocial behaviours
● personality functioning, coping strategies, strengths and vulnerabilities
● comorbid mental disorders (including depression and anxiety, drug or
alcohol misuse, post-traumatic stress disorder and other personality
disorders)
● the need for psychological treatment, social care and support, and
occupational rehabilitation or development
● domestic violence and abuse.
4.2.4.2 Staff involved in the assessment of antisocial personality disorder in
secondary and specialist services should use structured assessment meth-
ods whenever possible to increase the validity of the assessment. For foren-
sic services, the use of measures such as PCL-R or PCL-SV to assess the
severity of antisocial personality disorder should be part of the routine
assessment process.
4.2.4.3 Staff working in primary and secondary care services (for example, drug
and alcohol services) and community services (for example, the probation
service) that include a high proportion of people with antisocial person-
ality disorder should be alert to the possibility of antisocial personality
disorder in service users. Where antisocial personality disorder is
suspected and the person is seeking help, consider offering a referral to an
appropriate forensic mental health service depending on the nature of the
presenting complaint. For example, for depression and anxiety this may
be to general mental health services; for problems directly relating to the
personality disorder it may be to a specialist personality disorder or foren-
sic service.
65
Access to services
4.2.4.4 People with antisocial personality disorder should not be excluded from
any health or social care service because of their diagnosis or history of
antisocial or offending behaviour.
4.2.4.5 Seek to minimise any disruption to therapeutic interventions for people
with antisocial personality disorder by:
● ensuring that in the initial planning and delivery of treatment, transfers
from institutional to community settings take into account the need to
continue treatment
● avoiding unnecessary transfer of care between institutions whenever
possible during an intervention, to prevent disruption to the agreed
treatment plan. This should be considered at initial planning of
treatment.
4.2.4.6 Ensure that people with antisocial personality disorder from black and
minority ethnic groups have equal access to culturally appropriate services
based on clinical need.
4.2.4.7 When language or literacy is a barrier to accessing or engaging with serv-
ices for people with antisocial personality disorder, provide:
● information in their preferred language and in an accessible format
● psychological or other interventions in their preferred language
● independent interpreters.
4.2.4.8 When a diagnosis of antisocial personality disorder is made, discuss the
implications of it with the person, the family or carers where appropriate,
and relevant staff, and:
● acknowledge the issues around stigma and exclusion that have charac-
terised care for people with antisocial personality disorder
● emphasise that the diagnosis does not limit access to a range of appro-
priate treatments for comorbid mental health disorders
● provide information on and clarify the respective roles of the health-
care, social care and criminal justice services.
Organisation and planning of services

4.2.4.9 Provision of services for people with antisocial personality disorder often
involves significant inter-agency working. Therefore, services should
ensure that there are clear pathways for people with antisocial personality
disorder so that the most effective multi-agency care is provided. These
pathways should:
● specify the various interventions that are available at each point
● enable effective communication among clinicians and organisations at
all points and provide the means to resolve differences and disagree-
ments.
Clearly agreed local criteria should also be established to facilitate the transfer of
people with antisocial personality disorder between services. As far as is possible,
shared objective criteria should be developed relating to comprehensive assessment
of need and risk.
66
4.2.4.10 Services should consider establishing antisocial personality disorder

networks, where possible linked to other personality disorder networks.
(They may be organised at the level of primary care trusts, local authori-
ties, strategic health authorities or government offices.) These networks
should be multi-agency, should actively involve people with antisocial
personality disorder and should:
● take a significant role in training staff, including those in primary care,
general, secondary and forensic mental health services, and in the
criminal justice system
● have resources to provide specialist support and supervision for staff
● take a central role in the development of standards for and the coordi-
nation of clinical pathways
● monitor the effective operation of clinical pathways.
4.3 TRAINING, SUPERVISION AND SUPPORT
This section is concerned with the training, supervision and support required to
deliver effective care for people with antisocial personality disorder. It begins with a
review of relevant research of staff experience in the field of personality disorder
before considering more specific reviews and policy documents in relation to training
and supervision.
4.3.1 Direct studies of staff experience
A systematic review of the literature was conducted. Information about the databases
searched and the inclusion/exclusion criteria used for this section of the guideline can
be found in Table 2.
Table 2: Databases searched and inclusion/exclusion criteria for studies

of staff experience
Electronic databases MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC

Date searched Database inception to May 2008
Study design Any quantitative or qualitative
Patient population Staff in the direct care of service users with antisocial
personality disorder, psychopathy or personality disorder
Interventions Not applicable
Outcomes Experience of care
Settings Primary, secondary, tertiary or prison
67
The identified papers were discussed by the NCCMH team and GDG members
including service user representatives. A number of themes were identified from the liter-
ature and these themes were used to structure the review, namely: attitudes to personal-
ity disorder; self-awareness; clinical support; safety concerns and staff dynamics.
Attitudes to personality disorder

In a study by Mercer and colleagues (2000), 30 forensic nurses were asked to discuss
hypothetical vignettes of perpetrators of serious crimes (such as murder or serial rape)
who were likely to fit criteria for severe antisocial personality disorder. Where the
behaviour was seen as rational or purposeful, nurses considered this ‘evil’ and ther-
efore de facto beyond the scope of treatment. However, where there were signs that
the behaviour could be attributed to a diagnostic framework such as ‘schizophrenia’
or ‘psychosis’, the individual was more readily offered understanding (Mercer et al.,
2000). Interestingly, a comparison between the attitudes of psychiatric nurses and
prison officers (Bowers et al., 2006) found the latter more likely to view prisoners
with personality disorder as being cognitively incompetent, which may explain why
prison officers also tended to be more accepting of these individuals than nurses.
When personality disorder appears to staff as being all-encompassing and
untreatable, perhaps compounded by a perception that there is a deep-seated entity of
‘badness’ in the service user (Mercer et al., 2000), a sense of hopelessness and power-
lessness ensues; it is not therefore surprising when a therapeutic relationship between
the staff and service user fails to develop (Nathan, 1999). The notion of ‘therapeutic
pessimism’ is one that is repeatedly highlighted in the literature (Mercer et al., 2000;
Bowers, 2002; Carr-Walker et al., 2004; Stalker et al., 2005; Kurtz, 2005; Crawford
& Rutter, 2007). Such negative attitudes could be challenged through educating staff
about the current state of knowledge underpinning effective interventions for antiso-
cial personality disorder (Kurtz, 2005), including the gaps in the research, and by
encouraging staff to have a stronger belief in the effectiveness of their own personal
skills (Carr-Walker et al., 2004). More practically, the development of dedicated
personality disorder services could provide opportunities for staff to see for them-
selves that treatment is possible (Crawford & Rutter, 2007).
Given the lack of clarity and agreement among staff regarding the concepts of
psychopathy and personality disorder (in particular antisocial personality disorder
and DSPD), there is also an identified need for training to address these issues
(Haddock et al., 2001; Huband & Duggan, 2007). For example, the use of labels such
as ‘psychopath’ or ‘DSPD’ may be counterproductive and widen the chasm between
staff and service users (Kurtz, 2005). Others, such as Wright and colleagues (2007),
further argued that training should encourage staff to think about service users as indi-
viduals, thereby possibly helping them to form more supportive and caring therapeu-
tic relationships.
Bowers (2002) found that nurses with positive attitudes towards people with person-
ality disorder were likely to interact better with service users as well as colleagues,
report lower levels of work stress and perform better in the workplace. A more encour-
aging finding from Bowers and colleagues’ later research (Bowers et al., 2005; 2006), an
18-month longitudinal questionnaire study of 59 prison officers in a newly established
68
DSPD unit, was that staff attitudes to personality disorder were amenable to positive
change, probably as a result of social processes operating through interactions with the
service users. Staff considered getting to know inmates as individuals as positive expe-
riences (Bowers et al., 2005). Indeed through these processes, staff felt better able to
understand what underlay inmates’ particular behaviours, and more readily recognised
that different prisoners have different needs (Bowers et al., 2005).
Self-awareness
A consistent theme emerging from the literature was the importance of staff’s self-
awareness in their interactions with people with personality disorders. Wright and
colleagues (2007) argued that self-reflection could give rise to more meaningful
engagement with service users, not only because problems with interpersonal
processes are fundamental to personality disorders, but also staff can begin to make
sense of challenges in the therapeutic relationship as not just being attributable to the
service user (or their personality disorder), but also to staff themselves. Indeed,
unhelpful responses from staff could often be responsible for compounding service
users’ problems (Stalker et al., 2005).
Group-based supervision might provide opportunities for staff to self-reflect and
to air their emotions in relationship with others. For example, staff at Grendon
Underwood prison, where the majority of inmates are diagnosed with personality
disorder, have developed staff sensitivity groups as a coping strategy for dealing with
the difficult emotions arising from their work (Shine, 1997).
In an exploratory study, Kurtz and Turner (2007) interviewed staff working in a
medium security unit for offenders with personality disorder. Staff felt that working
with service users’ interpersonal problems sometimes meant staff themselves had to
confront their personal difficulties in order to detach from the service users’ problems.
Kurtz (2005) highlighted the importance of regular individual supervision to promote
a reflective approach to practice, but also suggested that is important to distinguish it
from a more managerial or evaluative type of supervision.
Clinical support
Clinical supervision specific to personality disorder is considered particularly important
and beneficial for staff who may not have come from a health or social care back-
ground (for example prison officers), who nevertheless deal with individuals with
personality disorder on a regular basis. Indeed the exploratory study in Grendon
Underwood (Shine, 1997) highlighted the lack of specific training among the majority
of the prison staff to deal with some of the particularly challenging incidents they
faced (such as inmates’ confrontations and hostile interactions), which were less
frequent in other prisons.
In a similar vein, the majority of staff from different agencies interviewed by
Huband and Duggan (2007) reported having had basic training to deal with specific
behavioural problems such as aggression, but this did little to further their understand-
ing of personality disorder. Staff felt they would value scenario-based training to
complement conventional approaches (Huband & Duggan, 2007). Likewise in the study
of 11 community-based personality disorder pilot services (Crawford & Rutter, 2007),
69
staff found training focused on both personality disorder-specific issues as well as

general principles desirable, especially when delivered by people directly involved
in providing services. Staff also found training delivered to teams, rather than to
individual staff, most effective (Crawford & Rutter, 2007).
Safety concerns
Findings from Carr-Walker and colleagues (2004) suggest that nurses working in high
security psychiatric hospitals would benefit from more comprehensive training on
security and safety issues, which are already available to prison officers.
Staff dynamics
Kurtz and Turner’s (2007) exploratory study showed that while staff in a medium
security unit readily recognised the value of organisational structure and purpose, and
a sense of belonging within that structure (through positive collaboration with
colleagues), they also felt isolated from other colleagues who did not understand the
nature of personality disorder or the work involved, and sometimes even within their
own team. Staff sometimes found it harder to manage difficulties with colleagues than
with service users, because of the absence of a safe and open forum for discussion
(Kurtz & Turner, 2007).
Arising from these observations, Kurtz (2005; Kurtz & Turner, 2007) suggested
that organisations should have in place regular group supervision provided by an
external consultant, who can provide an impartial view. This is particularly important
in light of the experiences of Moore and Freestone (2006) in setting up community
meetings in a DSPD unit, where they encountered staff reluctance to bring up issues
for fear of exacerbating them, especially in the context of meetings that also included
service users. Supervision groups with staff alone should therefore provide a ‘bound-
aried space’ to reflect on relationships with colleagues, and anxieties arising at the
organisational level (Kurtz, 2005; Kurtz & Turner, 2007). Supervision also should
focus on a coherent understanding of the organisational tasks and ideally include
senior staff who interface with external organisations and can bring a broader context
to the work of the frontline staff.
4.3.2 Policy documents and related reviews of staff experience
The identified papers for this section were discussed by the NCCMH team and GDG
members (including service user representatives). A number of themes were identified
from the literature and these were used to structure the review, namely: the content of
current training; the need for practice development and supervision; quality assurance;
and external monitoring.
Content of current training

The Department of Health document, Personality Disorder: No Longer a Diagnosis
of Exclusion (Department of Health, 2003) looked specifically at the provision of
training for personality disorder services and found that many clinicians were reluctant
70
to work with people with personality disorders because they felt they lacked the
skills, training or resources to provide an adequate service. This was no doubt
related to the lack of adequate training in the area (Department of Health, 2003).
Furthermore, in a preliminary study for the document, staff were poorly prepared
across all disciplines by their core professional training to work within these services
(Duggan, 2002). The report identified a significant lack of training for staff working
within general adult mental health services, in primary care, social services, social
housing or the voluntary sector (Duggan, 2002). It appears that training was based on
meeting the immediate needs and interests of staff, and not strategically planned nor
based on the required competencies or any underlying theoretical models (Duggan,
2002). There was also a lack of training to address the special needs of women and
people from black and minority ethnic groups (Duggan, 2002).
There is university-based training offering awards in specific therapeutic tech-
niques including cognitive behavioural or analytical therapy, dialectical behaviour
therapy, therapeutic environments and forensic aspects (Duggan, 2002). The prelimi-
nary report found that this training is largely targeted towards staff with an existing
professional qualification who have an interest in personality disorder and/or work-
ing in tertiary services providing highly specialised treatment and support regimes
(Duggan, 2002). Although of real value, these courses failed to meet the needs of
many staff without existing qualifications and/or who did not work in specialist units.
This suggests that any framework for training in personality disorder services
should provide for not only mental health staff but for staff working in primary care and
other agencies. Such training should be: (a) team focused with training in team building
and team working; (b) supported and valued by the organisation including having iden-
tified resources and cover provided where necessary to free up staff to attend training;
(c) appropriately targeted, ensuring that training meets the different needs within the
organisation; and (d) responsive to local need and services (ESMHCG, 2005).
Need for practice development and supervision

However, it is well established that training alone is not sufficient to improve compe-
tence (Roth & Pilling, 2008). Supervision and practice development systems need to
be in place if the full benefits of training are to be realised.
A preliminary report commissioned for Personality Disorder: No Longer a
Diagnosis of Exclusion (Department of Health, 2003) explored the competences and
attributes ideally required by staff to work effectively with people with personality
disorder (Duggan, 2002). The scope found a large number of similarities in the compe-
tences required of practitioners to work effectively within personality disorder services
and those required of mental health staff more generally (Duggan, 2002). Some
competences that were more specific to personality disorder included: emotional
resilience, clarity about personal and interpersonal boundaries, and the ability to toler-
ate and withstand the particular emotional impact that work with personality disor-
dered patients can have on relationships within a team and services (Duggan, 2002).
Crawford and colleagues (2007) identified organisational, therapeutic and other
factors that service users and providers believe result in high-quality care for people
with personality disorder. The characteristics of staff that were felt to be most helpful
71
for working in specialist personality disorder services in the community were: a)

willingness to be responsive and work flexibly, but not at the expense of neglecting
appropriate boundaries; (b) the ability to empower service users, even if this meant
letting them make some mistakes; (c) emotional maturity and a high degree of
personal resilience; (d) the ability to retain a positive attitude while accepting the
limits of what can be done; (e) a capacity and willingness to reflect on themselves and
their work and to discuss their mistakes or uncertainties; and (f) willingness to work
as members of a team and accept the process of shared decision making (Crawford
et al., 2007). A full list of the capabilities required by staff at all levels of their careers
who work with people with personality disorders is available in The Personality
Disorder Capabilities Framework (National Institute of Mental Health in England,
2003); these are the recommended competences by the Department of Health in their
planning and delivery guides to DSPD units (Home Office, 2005a; 2005b).
4.3.3 Quality assurance
Training for staff in specialist services is most likely to be accredited and quality
assured through contact with credible university providers (Duggan, 2002). The
preliminary report found that no such assurances can be given in relation to any other
type of training and suggests that a future training strategy must reflect the evidence
base and incorporate processes for assuring and maintaining quality (Duggan, 2002).
The comprehensive quality assurance programme developed by the prison service for
their offender management programmes (Gill Attril, presentation to the GDG, 2007)
is a potential model because it contains a combination of routine direct observation
of the delivery of the intervention with explicit audit criteria and both external and
internal monitoring.
4.3.4 External monitoring
All arrangements and services for people with personality disorder should be subject
to regular review, evaluation and audit as recommended by the ESMHCG (2005). In
the planning and delivery guide for high security services for people with DSPD,
external evaluation and validation of all aspects of service delivery and of the
outcomes achieved are reported to form the key components of the programme that
will be commissioned centrally (Home Office, 2005a). Beyond the process of external
evaluation, DSPD units are expected to evaluate and validate their own facilities,
treatments and interventions (Home Office, 2005b).
4.3.5 Summary of training, supervision and support
The overall impression from reviewing the studies of both staff experience and
training suggests that staff too often feel excluded and misunderstood and
72
frequently feel they have little relevant training in understanding or managing

antisocial personality disorder. This may be compounded by the fact that the
stigma that affects the patients may be transferred to staff. There is often a lack of
clarity about the purpose and function of some services and this may exacerbate
the difficulties in coping with the dual function of treatment and social control.
Therefore it is important that effective training, continuing staff support and
supervision systems are in place and that these are linked to and explicitly
supported by clear operational policies. These policies need to set out clearly the
goals, objectives and support structures that are routinely available. Links with
external agencies through regular support and supervision meetings are important
in keeping an open and reflective environment. Being part of, and integrated into,
established and clear care pathways, with referrals in and out of specialist residen-
tial services, may also be important. Working in services for people with antisocial
personality disorder presents a considerable challenge for staff including maintain-
ing a proper fidelity to the intervention model and managing the emotional
pressure this involves. Effective training and support is crucial to ensuring that
this happens.
Staff competence
4.3.6.1 All staff working with people with antisocial personality disorder should
be familiar with the ‘Ten essential shared capabilities: a framework for the
whole of the mental health practice’3 and have a knowledge and awareness
of antisocial personality disorder that facilitates effective working with
service users, families or carers, and colleagues.
have skills appropriate to the nature and level of contact with service users.
These skills include:
● for all frontline staff, knowledge about antisocial personality disorder
and understanding behaviours in context, including awareness of the
potential for therapeutic boundary violations (for example, inappropri-
ate relations with service users)
● for staff with regular and sustained contact with people with antisocial
personality disorder, the ability to respond effectively to the needs of
service users
● for staff with direct therapeutic or management roles, competence in
the specific treatment interventions and management strategies used in
the service.
3Available from www.eftacim.org/doc_pdf/10ESC.pdf
73
4.3.6.3 Services should ensure that all staff providing psychosocial or pharmaco-
logical interventions for the treatment or prevention of antisocial personality
disorder are competent and properly qualified and supervised, and that
they adhere closely to the structure and duration of the interventions as set
out in the relevant treatment manuals. This should be achieved through:
● use of competence frameworks based on relevant treatment manuals
● routine use of sessional outcome measures
● routine direct monitoring and evaluation of staff adherence, for exam-
ple through the use of video and audio tapes and external audit and
scrutiny where appropriate.
Supervision and support

4.3.6.4 Services should ensure that staff supervision is built into the routine working
of the service, is properly resourced within local systems and is monitored.
Supervision, which may be provided by staff external to the service, should:
● make use of direct observation (for example, recordings of sessions)
and routine outcome measures
● support adherence to the specific intervention
● promote general therapeutic consistency and reliability
● counter negative attitudes among staff.
4.3.6.5 Forensic services should ensure that systems for all staff working with
people with antisocial personality disorder are in place that provide:
● comprehensive induction programmes in which the purpose of the
service is made clear
● a supportive and open environment that encourages reflective practice
and honesty about individual difficulties such as the potential for
therapeutic boundary violations (such as inappropriate relations with
service users)
● continuing staff support to review and explore the ethical and clinical
challenges involved in working in high-intensity environments,
thereby building staff capacity and resilience.
4.3.6.6 Staff providing interventions for people who meet criteria for psychopathy
or DSPD should receive high levels of support and close supervision, due
to increased risk of harm. This may be provided by staff outside the unit.
4.4 SERVICE USER EXPERIENCE OF CARE AND SERVICES
4.4.1 Introduction
There are few studies exploring the views and experiences of people with personality
disorder, and even fewer that represent the experience of those with antisocial person-
ality disorder. In part this is due to the difficulties posed by interviewing people in
high security environments (Faulkner & Morris, 2002). In the review of the literature
that follows some of the studies were of a mixed sample of people with different types
74
of personality disorder; where the studies were specific about people with antisocial
personality disorder this has been noted.
A systematic review of the literature was conducted, which identified 15 studies
which were included in the review. Information about the databases searched and the
inclusion/exclusion criteria used for this section of the guideline can be found in
Table 3.
The identified papers were discussed by the NCCMH team and GDG members
(including service user and carer representatives). A number of themes were identi-
fied from the literature and these were used to structure the review. The themes were
grouped under two headings: experience of healthcare and related settings (including
diagnosis, stigma, and contact with healthcare professionals; experience of personal-
ity disorder; coping strategies; experience of services; and treatment preferences) and
experience of secure hospitals and the criminal justice system (including prison and
special hospitals; transfer from prison to hospital; and the DSPD programme).
4.4.2 Experience of healthcare and related settings
Diagnosis, stigma, and contact with healthcare professionals

In a study by Castillo (2000) people diagnosed with personality disorder interviewed
others to ascertain what it felt like to have the diagnosis, the problems people experi-
ence, and what they have found helpful in dealing with these problems. When asked
about the diagnosis, of the 50 people in the sample (14 of whom—11 men and 3
women—had dissocial personality disorder), 22% said that it was ‘a label you get
when “they” don’t know what else to do’, and 10% regarded having personality disor-
der as something ‘bad’ or ‘evil’ and a ‘life sentence—untreatable—no hope’ (Castillo,
2000). Over 50% were told their diagnosis by their psychiatrist, but 16% found out
accidentally from their records, which may have exacerbated their feelings of stigma,
Table 3: Databases searched and inclusion/exclusion criteria for studies

of service user experience
Electronic databases MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC

Date searched Database inception to May 2008
Study design Any quantitative or qualitative
Patient population Service users with antisocial personality disorder,
psychopathy or personality disorder
Interventions Not applicable
Outcomes Experience of care
Settings Primary, secondary, tertiary or prison
75
shame and exclusion: ‘After I was discharged I opened a letter from my psychiatrist
to the GP. It said it there. I was a bit stumped—shocked. I’d heard about people that
had been diagnosed with personality disorder being the black sheep of the commu-
nity. It made me feel I didn’t belong anywhere’ (Castillo, 2000). When asked what
they thought the diagnosis meant, 22 said that it had led to them not being treated with
respect by healthcare professionals: ‘Staff didn’t want to know’; ‘Told I was attention
seeking’ (Castillo, 2000). The categorisation of personality disorder as an Axis II
disorder was also felt to have some bearing on how they were perceived: ‘Treated less
sympathetically. . .not mental illness—something you have brought on yourself’;
‘People don’t believe there’s anything wrong with you if you’ve got personality
disorder’ (Castillo, 2000). Ten people described having a mixture of good and bad
treatment: ‘In one area they may give you help. In another area you don’t get help.
It’s very patchy’ (Castillo, 2000). Only two people were wholly positive about how
they had been treated.
The participants of a focus group convened by Haigh (2002) thought that the term
‘personality disorder’ was associated with stigma and that healthcare professionals
viewed people with the condition as untreatable. They felt that because of the
diagnosis they were excluded from some services. The term ‘antisocial personality
disorder’ was thought to be even more of a burden and it was felt that mental health
services were not well-equipped to meet the needs of people with the disorder. The
participants felt anxious about the term ‘dangerous and severe personality disorder’,
particularly that it would be applied to them and they would be detained (Haigh,
2002). It was strongly stated by the participants that they required high-quality
printed information about personality disorders, and that they should not be actively
discouraged from seeking information by professionals. It was suggested that service
users should help train healthcare professionals in managing people with personality
disorder, particularly in terms of developing empathy and understanding (Haigh, 2002).
In a study by Stalker and colleagues (2005), which elicited the views of ten people
with a diagnosis of personality disorder, half felt that the term ‘personality disorder’
was disparaging. However one male participant thought that it accurately described
his problems: ‘It doesn’t particularly disturb me. I don’t see any problem because that
is exactly what I suffer from—a disorder of the personality’ (Stalker et al., 2005). In
contrast with Castillo (2000), the majority of the participants were positive about their
contact with healthcare professionals. It should be noted that the sample size in
Stalker and colleagues (2005) was much smaller, containing eight women and only
two men, and probably consisted predominantly of people with borderline personality
disorder (the type of personality disorder was not stated).
Experience of personality disorder

Castillo and colleagues (2001) found high incidences of abuse, self-harm and suici-
dal behaviour, whether the diagnosis was borderline or dissocial personality disorder.
Of the 50 participants, 88% had experienced abuse, most of it occurring in childhood,
and many thought that this was the cause of their difficulties. Women with dissocial
personality disorder had all experienced emotional abuse in childhood; none had a
history of being violent as a child but 67% had gone on to be violent to other people.
76
Interestingly, 50% of the men with a diagnosis of dissocial personality disorder

considered their positive attributes to be care and compassion; they characterised
themselves as having a ‘Jekyll and Hyde’ persona, that is having a combination of
compassionate and aggressive tendencies (Castillo et al., 2001). Thirty-eight percent
of Castillo’s sample had been imprisoned: ‘I’m confused—can’t get a job because of
my prison record—my mum doesn’t want to help me—I damage things—have lost my
temper with guns and knives—told I can’t be helped’ (Castillo, 2003).
The participants in Castillo (2000) questioned the category of ‘personality disorder’
when they said that they thought their primary problems were depression, abuse,
stress or not coping, and substance misuse. In the survey by Stalker and colleagues
(2005), participants said that the main problem in their lives was in making and keeping
relationships, often because they felt unable to trust other people.
Coping strategies
In Stalker and colleagues (2005), the participants in the survey recognised a number
of strategies they employed to help them cope. The most common approaches
included: visiting a mental health resource centre; talking to a professional or a partner;
keeping active; exercise; going to bed; medication; ‘keeping yourself to yourself’;
‘fighting the illness’; use of drugs and alcohol; overdosing; and cutting. The partici-
pants acknowledged that some of these activities were harmful, but felt they had no
alternatives: ‘When I am feeling really bad, [drinking is] the only thing that really
blots out the memories’ (Stalker et al., 2005).
Experience of services
Accessing mental health services can be problematic for many people with personal-
ity disorder. Strike and colleagues (2006) suggested in a Canadian qualitative study
that this was a particular problem for men with severe personality disorder (some of
whom had antisocial personality disorder) who were suicidal and had a history of
substance misuse. They found that negative experiences with mental health services
resulted in men with severe personality disorder not wishing to access services until
there was a crisis. Consequently they received the majority of their treatment and care
through emergency departments; often they were taken to hospital involuntarily
because of disturbing and/or dangerous behaviour. The care they received in the
emergency departments did little to improve the men’s views of mental health serv-
ices and did not result in them accessing mental health services in the future. In a
further qualitative study of the same sample of people (Links et al., 2007), partici-
pants (17 out of 24 had antisocial personality disorder) spoke of the reasons why they
avoided emergency departments, including long waiting times, seeing lots of differ-
ent healthcare professionals, the possibility of being confined, anxiety about losing
control, feeling ashamed and being discharged before their crisis had been dealt with
properly. One participant explained: ‘the hospital is always my last resort, because
usually when I come to hospital I end up feeling worse because of the whole proce-
dure and process, and the waiting and. . .it’s more nerve-wracking for me’ (Links
et al., 2007). Sometimes the staff were ‘rude’ and ‘dismissive’, and participants
suggested that training and attention to interpersonal interactions were required. It was
77
also suggested that one way of improving access to emergency psychiatric treatment
would be having separate psychiatric emergency services or triage points.
In the Castillo survey (2000), 34% said that they wanted improved services. The
themes that emerged included: being listened to; being treated with respect; health-
care professionals having a greater understanding of the condition; being given more
information; being offered less medication and more ‘talking therapies’. Other people
said that out-of-hours or helpline services would be useful. When asked what had
helped them, 34% mentioned their therapists, 26% said medication, 24% noted
psychiatrists, hospital or hospital key worker, and 22% singled out their community
mental health team for praise.
A lack of services tailored to their needs has also been highlighted by people with
personality disorder (Haigh, 2002). The majority of the participants in the focus
group convened by Haigh (2002) had had negative experiences in general mental
health services, although those referred for specialist treatment were more positive.
Participants also highlighted that it would be helpful if there was a 24-hour phone
support service that could be used during a crisis, and that GPs received education
about personality disorders and how to manage them. Because engagement with
services can often be problematic, it was suggested that a mentoring/befriending
service with ‘adult fostering’ might be beneficial. Participants said that in an ideal
world they would like a local centre providing holistic approaches to the myriad
difficulties experienced by people with personality disorder (Haigh, 2002). For
larger areas, there should ideally be some form of therapeutic community with
outreach services; these would be day services, on the whole, which would enable
the service user to forge stronger links with their local community.
Treatment preferences
The participants in the Haigh (2002) study felt that being offered options for treatment
was helpful, and that there was an over-reliance on drug treatment. They emphasised
that they had important views on treatment (that is, what helped them and did not help
them) and that staff should listen to them when deciding on interventions (Haigh,
2002). They also stressed the importance of early intervention in adolescence to
prevent the deterioration of symptoms in adulthood.
In Castillo and colleagues’ survey (2001) of 50 people with personality disor-
der, cognitive analytic therapy was the most highly rated of the therapies, although
it was not made clear whether those rating it were people with antisocial personality
disorder.
In a survey of 12 male patients of a highly specialist personality disorder hospital
treatment unit (McMurran & Wilmington, 2007), nine of whom had antisocial
personality disorder, both psychoeducation and social problem-solving therapies were
thought to be ‘useful’ by this group. The majority found psychoeducation ‘informa-
tive, interesting and helpful’, social problem-solving therapy was thought to be
‘generally helpful’ and the group work was viewed as ‘enriching the problem-solving
process’. However, the patients also suggested ways of improving the interventions.
For psychoeducation this included reducing the waiting time between being assessed
and being given feedback and receiving support afterwards for any distress caused by
78
learning more about their condition. For social problem-solving therapy, suggested
improvements involved more frequent reviews of how well the therapy was working,
more consistency in how the treatment was delivered, helping patients to draw out
problems, supporting them during group therapy, and developing an advanced form
of the intervention. For both interventions the patients thought that providing further
written information would be helpful.
4.4.3 Experience of secure and criminal justice settings
Prison and special hospitals

During the Fallon Inquiry (Fallon et al., 1999) eight patients treated in the Personality
Disorders Unit of Ashworth Special Hospital were interviewed. The themes identified
included length of stay in the hospital, the mix of patients in the Personality Disorders
Unit, access to treatment, and a comparison of hospital versus prison.
One concern was continued detention. One patient (Patient A) said that because
he did not have any continuity of care with his RMOs they were reluctant to consider
discharge or allow him leave of absence from the ward. Patient A was concerned that
the more he revealed in therapy sessions, the more this provided ‘ammunition’ for his
continued detention: ‘ . . . it became apparent that talking was actually a bad thing
and basically it has got to the stage now where I tell them absolutely nothing. In fact
I do not cooperate with treatment now’. Patient A was not told when he might be
transferred to a medium security unit, why he was detained in a high security hospi-
tal, and how the Personality Disorders Unit and treatment were going to benefit him.
Some of the other patients were also critical of the length of time it took before being
reviewed for a medium security unit. Some felt that if they had been in prison they
would not have spent as long being detained:
‘That is the worst part of being a special hospital patient. You are sentenced to
natural life imprisonment in a mental institution and from there . . . it is down to
a lottery whether you ever get out: whether your doctor is competent, whether
the RSU [regional secure unit] doctor likes you and is competent, whether the
RSU wants you considering the pressures on RSU beds’. (Patient H).
Patient B felt that the unit itself was a problem in that it segregated the people with
personality disorder from other patients, and could lead to the creation of a ‘better
psychopath’, by enabling them to become more manipulative and clever.
Experiences of treatment were mixed. Patient B was positive about the hospital
and said he recognised he had problems that needed to be treated, and entered into
treatment willingly. He did, however, have some doubts about the value of group
work and he saw nurses as ‘more security guards than therapists’. Both Patient A and
Patient C felt that the treatment options were very limited. For Patient A treatment
consisted of therapy with a primary nurse and a few meetings with a psychologist.
Patient C had a number of hours of ‘psychology work’, although he had declined an
offer of a place on a group for sex offenders. He thought of his being detained in
79
Ashworth as not therapeutic but preventive. Patient E had attended several different
groups, including anger management and a sex offenders’ group. The sex offenders’
group had forced him to face what he had done as he had previously not thought of
himself as a sex offender, and it had also addressed the causes behind his offences.
However, he was critical of the lack of ‘imaginative’ treatments that enable patients
to move forward.
Patient F was critical of the treatment in Ashworth, comparing it negatively with
the treatment he had first received in Broadmoor which had enabled him to make
positive personal developments and he had appreciated having support after therapy
sessions had ended. Patient G remarked on the fact that a specialist hospital could not
provide the treatments that had been recommended for him (a neuropsychological
assessment, cognitive skills work and further psychological interventions); he was
told that he had to wait 2 years for these interventions. Patient D, who had refused
treatment, said that what was most beneficial to him was discussing matters with
other patients.
In a study by Ryan and colleagues (2002), which aimed to capture the voice of
people with personality disorders detained in Broadmoor about treatment and serv-
ices, 61 people were interviewed. The aim was to feedback these views to the govern-
ment’s advisers developing the DSPD programme. Six men and two women had a
diagnosis of dissocial personality disorder, and 31 men had a ‘mixed’ diagnosis. The
main themes that emerged from the study were: preferences about the nature of
detention; experience of prison; the qualities of the staff; their perceptions of being
vulnerable; what helped them; and what would be the traits of an ‘ideal’ service.
Regarding preferences about the nature of detention, almost 50% said that they
preferred the ‘status quo’; 13 said they would like to go back to prison and 19 said
they wanted to be ‘somewhere else’. Asked to give three reasons for their choices, 29
closely matched this response: ‘Because of the security here there is very little to feel
threatened by, so it is easier to talk about things, you can’t soften up in prison as there
are too many bullies, too many people wanting to take advantage of you’. Twenty-
nine people gave a response similar to the following: ‘In prison you are in a cell and
haven’t got rehabilitation services, at Broadmoor you are able to look at the crime
and your mental illness, you have caring staff and open spaces, in hospital the illness
is your crime, in prison you receive punishment.’ Thirteen said they would prefer to
be back in hospital because they ‘didn’t like people’ and wanted their ‘own space’.
When compared with Broadmoor, people felt that the positive aspects about
prison were having an earliest date of release, ‘realisation of situation’, education,
and ‘other factors’ including exercise. Thirteen of those who responded and had been
imprisoned (56 in total) had more than one negative comment to make about prison,
the main factor being the lack of treatment in prison.
When questioned about qualities of staff, the most important quality by some
margin was being caring and understanding. Almost 50% felt that staff should be
experienced in working with people with personality disorder.
Fifty-six out of the 61 people interviewed said that they felt vulnerable. There
were three main reasons for this: other people, therapy, and their own mental illness.
Men were more likely than women to feel vulnerability when ‘facing their situation’.
80
The most popular way of coping with these feelings was talking it over with staff,
although seven people said that they self-harmed or used drugs or alcohol.
The most favoured treatment by 66% was individual therapy, however this was
influenced by gender and by type of disorder. A greater proportion of the men
favoured this treatment, as did people with a mental illness in addition to personality
disorder. The vast majority could name one treatment that had been helpful. Only one
person said that no treatment had been beneficial. Just over 50% said they wanted
improved access to treatment, and ‘more in-depth groups, which don’t skirt around
the issues’ because ‘personality disordered people need to be confronted’. The inter-
mixing of people with different diagnoses on the wards was also an issue; a third of
people were concerned about sharing a ward with a person with a mental illness.
However, a quarter of patients, said they would not have ‘personality disorder only’
wards because ‘they are all out to get each other, fighting and influence each other
into self-harming’.
According to another study (IMPALOX Group, 2007), use of medication may also
be a cause of concern for patients/prisoners. One prisoner interviewed thought that his
violent actions towards staff were due to being over-medicated with antipsychotics:
‘It was making me agitated, making things worse. I was sedated but at the same time
I was very paranoid. I could not think properly to figure out what was happening . . . I
felt threatened: if I didn’t get them, they would get me. I carried out 36 assaults in one
week in Ashworth: I was drugged out of my mind’.
In Grendon Underwood Therapeutic Prison, where the emphasis is on evidence-
based behavioural and cognitive techniques, one prisoner describes a therapeutic
community programme for dangerous, long-term offenders who are open to the idea
of exploring their behaviour and what may have caused it:
‘I have been given the time and space to work through and dismantle all the justi-
fications and cognitive distortions I used to excuse not only the behaviour of
those who abused me but also my own offending behaviour . . . I have learned to
see others as people with feelings and rights of their own, and not just as bodies
in which to take out frustration, anger or selfish gratification’ (Anonymous, 2001
quoted in Castillo, 2003).
Transfer from prison to hospital

The transfer of prisoners with personality disorders from prison to medium or high
security hospitals towards the end of their sentences for treatment may be unaccept-
able to the individual, who may prefer to receive treatment in the community (see
Fallon et al., 1999). A prisoner diagnosed with antisocial personality disorder, border-
line personality disorder, PTSD, panic disorder and substance misuse who was near-
ing the end of his sentence but was thought to be at high risk of re-offending, was
admitted to a medium-secure hospital with a specialised unit for personality
disordered offenders (Morris et al., 2007). The patient had strong views that he should
have been given the option not to be admitted. When told he was being transferred,
he self-harmed: ‘They’d snatched my life away. I’m not mentally ill. I’d had
problems. Long-standing problems. Things got worse for me’ (Morris et al., 2007).
81
His experience once in the hospital unit was more positive: ‘I was made to feel
welcome. People were nice to me. I’d stereotyped it—seclusion, sedatives, injections
every day—but when I got there it was relaxed. Everybody was alright’ (Morris et al.,
2007). He said he would have preferred not to have had treatment as it was not right
for him at that time, but he found the hospital environment, such as having structure
to the day, talking with other people, and his relationship with his psychiatrist, thera-
peutic (Morris et al., 2007).
The DSPD programme

In an evaluation of the assessment procedure for the DSPD programme (IMPALOX
Group, 2007), just over 50% of the 40 prisoners interviewed from HMP Whitemoor
and the Westgate Unit and HMP Frankland, who had volunteered for assessment, said
prior to the assessment programme they had not been given an opportunity by the
prison service or any other agency to consider the impact of personality on events and
behaviour, but that the programme itself had enabled them to think about themselves
and their behaviour (including offending and the use of violence) in a different way.
One individual commented about the programme: ‘My world view has been turned
upside down . . . It’s been a good ride. I find things out about me, I know they were
there. I’m pleased with me, and if I can get any more support, I’ll grab it. I should
have got it 20 years ago: but it’s not too late.’ (IMPALOX Group, 2007).
A few prisoners said that they had been able to control their aggression and
violent behaviour more effectively. One prisoner reflected that ‘I’ve never, ever not
been violent: trying or learning to control it is a major step for me. For 9 months
I’ve not attacked anyone. You challenge yourself, but on these programmes, convicts
challenge you also. But I’ve never previously taken criticism from anyone’
(IMPALOX Group, 2007).
However, others said that they were frustrated by the assessment process due to
delays and because it raised expectations and this led to feelings of irritability and the
‘propensity to minor violence’. Some were concerned about the lack of support after
the assessment was over: ‘The box is opened: I can’t shut it, and I can’t deal with it’
(IMPALOX Group, 2007). Overall, prisoners said that they valued the support from
psychiatrists and psychologists and the majority said that they would like more
contact with these professionals. Many were keen to start treatment.
In a corresponding study by Maltman and colleagues (2008) of patient perspec-
tives of DSPD assessment at Peaks Unit, Rampton Hospital, which was based on 12
semi-structured interviews, six main themes emerged: fear, shock, offering hope, the
label, information and coping with boredom.
Personal safety and prolonged detention were issues that were a source of ‘fear’
for the patients entering the unit. One patient thought that he was going ‘to be around
some really disturbed people. . .you hear that many stories of people like Hannibal
Lecter. . .’. However although some people expected there to be institutional violence,
this proved not to be the case. Some feared being detained for protracted periods: ‘It’s
like entering a twilight zone and not coming back out’ (Maltman et al., 2008).
Feelings of ‘shock’ were also expressed by the patients due to being admitted
unexpectedly near to the date of release from prison: ‘It was the day of my release and
82
it came as a shock’; ‘I thought I would finish my licence off in prison and get out a
free man, but it didn’t work like that.’ One man said that he was concerned about the
impact that his transfer would have on his family. The security levels in the unit were
also a cause of shock: ‘I got past the gate and it just reminded me of prison . . . going
through security . . . I was thinking, “Well this can’t be a hospital”’. Patients were also
shaken by staff attitudes and behaviour, and the use of ‘strong arm tactics’. One
patient described staff being ‘manipulative . . . pressing my buttons to see how I
reacted’. However, other patients were positive about staff (Maltman et al., 2008).
Being offered hope was also a recurrent theme in the interviews. Similar to the
IMPALOX study (2007) patients said that they ‘wanted to come to hospital to get
treatment’. Many of the patients reported that the assessment and therapeutic interac-
tions had been beneficial: ‘I actually get the feeling that people want us to move on
and . . . that gives me a reason . . . to do the best I can to get out.’ Meetings to plan care
were also viewed positively, and community meetings were thought to be of especial
benefit. However some participants felt that they were given ‘false hope’, especially
about potential length of stay, suggesting that people should be given realistic assess-
ment of their circumstances (Maltman et al., 2008).
4.4.4 People with ASPD and learning or physical disabilities,

and acquired cognitive impairments
As reviewed above, it is evident that the experience of many people with antisocial
personality disorder is of being excluded from services or from being involved in
decision-making concerning their care. This is also the experience of many people
with disabilities of various kinds. These include learning disabilities (for example,
Kunz et al., 2004), physical disabilities and acquired cognitive impairments (for
example, Darke et al., 2008), which are both more prevalent and associated with poor
outcomes in antisocial personality disorder. Given these facts, it is important that both
the antisocial personality disorder and the disability are recognised and effective
treatment offered. For many people little or no adjustment of the intervention
programmes will be required but where uncertainty about this exists specialist advice
should be sought.
4.4.5 Summary of service user experience
The review of service user experience suggests that a diagnosis of antisocial person-
ality readily brought disadvantages (for example, exclusion from services) and access
to the right kind of treatment is often difficult to achieve. The review also confirms
the position identified in Chapter 2, that people with antisocial personality disorder
have considerable mental health problems including drug and alcohol misuse, anxiety
and depression. Indeed some of the ‘coping strategies’, such as excessive alcohol
consumption, could be seen in part as a result of the lack of more effective and appro-
priate means to deal with some of the comorbid problems.
83
Service users clearly valued treatment, including psychoeducation and cognitive-

oriented treatments, but they also had a strong preference for positive relationships
with staff, which promoted their involvement in their care. For service users in long-term
care, being included in the design and planning of their care seemed particularly
important. Clarity about the purpose of their treatment, particularly in high security
environments, was also highlighted (echoing the needs of staff identified above) as
was a need for clarity about transfer between prison services and hospital. In community
settings, a positive engaging framework focused on achieving goals and objectives
and recognising the multiple problems and pathologies faced by people with antiso-
cial personality disorder is also important.
4.4.6.1 Staff, in particular key workers, working with people with antisocial
personality disorder should establish regular one-to-one meetings to
review progress, even when the primary mode of treatment is group based.
4.4.6.2 When working with women with antisocial personality disorder take into
account the higher incidences of common comorbid mental health prob-
lems and other personality disorders in such women, and:
● adapt interventions in light of this (for example, extend their duration)
● ensure that in inpatient and residential settings the increased vulnera-
bility of these women is taken into account.
People with antisocial personality disorder and acquired cognitive impairments

4.4.6.3 When a person with learning or physical disabilities or acquired cognitive
impairments presents with symptoms and behaviour that suggest antisocial
personality disorder, staff involved in assessment and diagnosis should
consider consulting with a relevant specialist.
4.4.6.4 Staff providing interventions for people with antisocial personality disor-
der with learning or physical disabilities or acquired cognitive impairments
should, where possible, provide the same interventions as for other people
with antisocial personality disorder. Staff might need to adjust the method
of delivery or duration of the intervention to take account of the disability
or impairment.
Autonomy and choice

4.4.6.5 Work in partnership with people with antisocial personality disorder to
develop their autonomy and promote choice by:
● ensuring that they remain actively involved in finding solutions to their
problems, including during crises
● encouraging them to consider the different treatment options and life
choices available to them, and the consequences of the choices they
make.
84
Developing an optimistic and trusting relationship

4.4.6.6 Staff working with people with antisocial personality disorder should
recognise that a positive and rewarding approach is more likely to be
successful than a punitive approach in engaging and retaining people in
treatment. Staff should:
● explore treatment options in an atmosphere of hope and optimism,
explaining that recovery is possible and attainable
● build a trusting relationship, work in an open, engaging and non-judge-
mental manner, and be consistent and reliable.
Engagement and motivation

4.4.6.7 When providing interventions for people with antisocial personality
disorder, particularly in residential and institutional settings, pay atten-
tion to motivating them to attend and engage with treatment. This should
happen at initial assessment and be an integral and continuing part of
any intervention, as people with antisocial personality disorder are
vulnerable to premature withdrawal from treatment and supportive
interventions.
Inpatient services
4.4.6.8 Healthcare professionals should normally only consider admitting people
with antisocial personality disorder to inpatient services for crisis manage-
ment or for the treatment of comorbid disorders. Admission should be
brief, where possible set out in a previously agreed crisis plan and have a
defined purpose and end point.
4.4.6.9 Admission to inpatient services solely for the treatment of antisocial
personality disorder or its associated risks is likely to be a lengthy process
and should:
● be under the care of forensic/specialist personality disorder services
● not usually be under a hospital order under a section of the Mental
Health Act (in the rare instance that this is done, seek advice from a
forensic/specialist personality service).
4.5 CARER EXPERIENCE
4.5.1 Introduction
The Care Services Improvement Partnership summarised the findings of the ‘Carers
and Families of People with a Diagnosis of Personality Disorder Conference’ held in
October 2005 (CSIP, 2006). The aim of the conference was to engage with carers to
find out what the impact of caring for people with personality disorder meant for
them, to identify areas for improvement and to identify good practice. The report of
that conference is summarised below.
85
4.5.2 Diagnosis and stigma
Carers stated that obtaining information about the diagnosis from healthcare profes-
sionals was difficult. They felt that psychiatrists did not want to use the term ‘person-
ality disorder’ and that they often lacked the skills and knowledge to help service
users with a personality disorder. Carers thought that people were diagnosed with
personality disorder once they had not responded to traditional treatment, rather than
receiving a diagnosis based on symptoms. Some carers felt that being given the
diagnosis had been helpful; however, they felt that because of the stigma associated
with the disorder, professionals were reluctant to give a diagnosis of personality
disorder for fear that their clients would be treated differently. Carers also reported
that the diagnosis ‘attracted less sympathy’ than a diagnosis of severe mental illness.
With regard to stigma, carers felt that overall they could talk to their friends and
neighbours about the difficulties associated with personality disorder, but that the
stigma came from the professionals not wanting to work with service users with the
diagnosis. There was a strong suggestion that training for staff (and carers) should
be developed to address this issue. Carers were confident that they had much to offer
to professionals and that education of staff should include specific content on the
needs of carers, with carers being involved in the training. There was a recognition
that personality disorder did not ‘sit comfortably’ within the healthcare system, and
that such training could help to address this problem.
4.5.3 Carers’ experience of staff, confidentiality and access to information
Carers felt that professionals often did not see beyond the service user and that staff
were not always sympathetic to their needs. Carers reported considerable anger at
having to care for family members to the point of hospitalisation, and then not to be
given any information about the person’s condition in hospital. GPs were felt by
carers to be an important entry point to gain information. People felt that even having
a poster in their GP’s surgery would be useful as this would either make them think
about talking to the GP regarding their responsibility of caring for someone with
personality disorder, or would encourage them to ask the GP about support services.
Where agencies were involved, carers felt that poor inter-agency communications
were the norm. Their experience was that professionals had limited knowledge of
other services. The carer often felt that they knew more about the bigger picture
than any single agency or professional but that their expertise and knowledge were
disregarded.
4.5.4 Support
Carers felt that time and direct support for them was important to help them cope.
They typically reported feeling very isolated, and though they acknowledged various
carer support groups, many felt that they had not been given any support to understand
86
the diagnosis of personality disorder. Carers expressed that they wanted access to
carers’ networks or self-help and support groups so that they could learn from other
people with similar experiences and also share good practice. Parents of people with
personality disorder were often left feeling to blame for their child’s problems. One
carer expressed that: ‘I need reassurance. I feel that somehow I have let my child
down, what could I have done differently, what can I do with these feelings?’ Carers
also felt that more work needed to be done around early intervention and that the issue
of parents with a personality disorder required further attention
4.5.5 Summary of carer experience
Carers of people with antisocial personality disorder often bear the major burden of
care. The nature of the antisocial and offending behaviour often associated with the
disorder may mean that carers are treated unsympathetically, although they them-
selves may have considerable needs as a result of the behaviour of their family
member. Carers are keen to be involved to gain more information and to build collab-
orative relationships with health and social care professionals. Families have the same
rights to support and containment as other families caring for a person with a signif-
icant mental health problem.
Involving families and carers

4.5.6.1 Ask directly whether the person with antisocial personality disorder wants
their family or carers to be involved in their care, and, subject to the
person’s consent and rights to confidentiality:
● encourage families or carers to be involved
● ensure that the involvement of families or carers does not lead to a
withdrawal of, or lack of access to, services
● inform families or carers about local support groups for families or
carers.
4.5.6.2 Consider the needs of families and carers of people with antisocial person-
ality disorder and pay particular attention to the:
● impact of antisocial and offending behaviours on the family
● consequences of significant drug or alcohol misuse
● needs of and risks to any children in the family and the safeguarding
of their interests.
4.6 OVERALL SUMMARY
This chapter covered the organisation of services and the experiences of staff who
provided them and the services users and carers who are in receipt of the services.
87
A number of common themes can be identified across all three areas, which include:
clarity about the purpose of the services provided; the need to challenge prejudice and
therapeutic pessimism; the need to involve staff, service users and carers in the
planning and delivering of care; and a significant increase in the range and quality of
training and the requirement to back this up with continuing support and supervision.
It also clear that this effort should not only be multi-disciplinary—if it is to be
successful it should also involve more than one agency.
88
Interventions in children and adolescents
5 INTERVENTIONS IN CHILDREN AND

ADOLESCENTS FOR THE PREVENTION OF
ANTISOCIAL PERSONALITY DISORDER
5.1 INTRODUCTION
The diagnostic criteria for antisocial personality disorder stipulate that there must be
evidence of conduct disorder in childhood (see DSM-IV; APA, 1994). This is consis-
tent with epidemiological and other evidence, which demonstrates an early develop-
mental trajectory for antisocial problems and other related difficulties (see Chapter 2).
These factors, taken together with the considerable pessimism that has existed regard-
ing treatment of antisocial personality disorder in adults, and the limited evidence that
has been collected demonstrating the effectiveness of such treatment, have led to an
increasing focus on interventions for children and their families to prevent the devel-
opment of conduct disorder and subsequent antisocial personality disorder.
As was highlighted in Chapter 2, the development of conduct or related problems in
childhood and adolescence does not mean that a person will inevitably develop antiso-
cial personality disorder. Estimates of the probability that children who develop conduct
disorder or related problems will go on to develop antisocial personality disorder gener-
ally range from 40% (Steiner & Dunne, 1997) to 70% (Gelhorn et al., 2007). Despite this
variation, it seems clear that preventive interventions targeting conduct disorders in chil-
dren have the potential to substantially reduce antisocial personality disorder occurrence
and/or severity. The reduction of the degree of distress and damage caused to children
and their families as a result of a child’s chronic conduct problems is itself, of course, a
worthwhile venture. The focus in this particular chapter, however, is on the longer-term
implications of treating and preventing conduct disorder in children and adolescents.
This chapter will first consider risk factors associated with the development of anti-
social personality disorder (see Section 5.2). This will be followed by assessing the
evidence regarding the effectiveness of early interventions for antisocial and other
behavioural problems and interventions targeting children at risk of developing
conduct disorder and antisocial personality disorder in later childhood or adulthood.
These interventions are primarily focused on risk factors related to the parent(s), rather
than the child, and they require at-risk children to be identified before the emergence
of symptoms, which may be in early childhood, infancy, or even during pregnancy (see
Section 5.3). The chapter will then consider separately the evidence regarding partic-
ular preventive interventions (see Section 5.4), including interventions that directly
target the child (for example, Kazdin, 1995), interventions addressing the parents (for
example Webster-Stratton, 1990), interventions directed at families (for example
Szapocznik et al., 1989) and interventions that simultaneously target families and the
wider social environment (for example Henggeler et al., 1992).
89
5.2 RISK FACTORS
5.2.1 Introduction
Early interventions for the prevention of antisocial personality disorders are reviewed
in Section 5.3. An important debate regarding public health interventions concerns
whether to focus these interventions on the population as a whole (universal preven-
tion) or on individuals more likely to develop the disorder in the future (selected and
indicated prevention). Universal prevention interventions seek to shift the population
distribution of the disorder as a whole with the aim that those at the extremes of the
distribution will benefit from this reduction in overall incidence of the disorder in the
population. In addition, as the population is the focus of the interventions those indi-
viduals with a greater risk of developing the disorder are not stigmatised (see
Farrington & Coid, 2003).
In contrast, selected and indicated preventative interventions require identifying
people at risk of developing the disorder and targeting them for intervention. The
advantage of this approach is that those at greatest risk receive intensive intervention
and therefore such an approach is more likely to be cost effective. However, there are
problems associated with the impact of labelling children (as has been discussed in
more detail in Chapter 2). A further difficulty is that currently there is no specific tool
or measure that can identify the relatively small number of people who go on to
develop antisocial personality disorder with particularly high precision (Moran &
Hagell, 2001). Advances in the knowledge of risk factors may enable identification of
those at greatest risk who might particularly require intervention (Hill, 2003).
Few studies have directly sought to identify risk factors for the development of
antisocial personality disorder (see Farrington & Coid, 2003). However, there are a
number of studies that have examined predictors of antisocial behaviour and/or
offending in adulthood that are likely to be informative in evaluating the developmen-
tal pathway to antisocial personality disorder.
5.2.2 Definition and aim of review
The aim of this review is to assess risk factors for the development of antisocial
personality disorder. Risk factors reviewed in this section fall into three main cate-
gories: individual (relating to the child), family (relating to the family of the child)
and social (relating to the social environment of the child).
5.2.3 Databases searched and inclusion/exclusion criteria
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Table 4. Only studies with outcome data
on offending and/or the proportion of participants meeting diagnostic criteria for anti-
social personality disorder or conduct disorder were included. Only cohort studies with
90
Table 4: Databases searched and inclusion/exclusion criteria for

clinical evidence
Electronic databases MEDLINE, EMBASE, PsycINFO, Cochrane

Library
Date searched Database inception to June 2008; table of contents
June 2008
Study design Prospective cohort studies
Patient population People with individual, family or social factors asso-
ciated with risk of developing antisocial personality
disorder
Interventions Psychosocial interventions
Outcomes Diagnosis of antisocial personality disorder, diagno-
sis of conduct disorder, offending behaviour
a minimum of 5 years’ follow-up period and a minimum age at follow-up of 15 years

were included.
5.2.4 Studies considered4
The review team conducted a new systematic search for cohort studies that assessed
the risk factors for developing antisocial personality disorder. Twenty-nine trials
examining clinical outcomes met the eligibility criteria set by the GDG. All were
published in peer-reviewed journals between 1989 and 2008. In addition, 22 studies
were excluded from the analysis. The most common reason for exclusion was that the
data were not extractable.
5.2.5 Clinical evidence for risk factors
Evidence from the important outcomes and overall quality of evidence are presented
in Table 5 (further information about included studies can be found in Appendix 17).
Studies used a variety of outcomes, therefore only very broad risk factors could be
combined in the meta-analysis. As expected, child behaviour problems were associated
with greater risk of antisocial personality disorder outcomes at preschool (odds ratio
[OR] ⫽ 1.91; 1.66, 2.19), middle school (OR ⫽ 2.56; 2.10, 3.12) and adolescence
4 Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capital
letters (primary author and date of study publication, except where a study is in press or only submitted for
publication, then a date is not used). The references for studies in this section can be found in Appendix 17.
91
Table 5: Study information and summary evidence table on risk factors for
developing antisocial personality disorder
Risk factors identified Risk factors identified Risk factors identified

in early childhood in mid childhood in adolescence
(0–5 years) (6–11 years) (12–18 years)
Total no. 6 studies 17 studies 10 studies
of trials
Study ID BOR2004 BABINSKI1999 FARAONE1997
FERGUSSON1994 BIEDERMAN1996 FARMER2004
KOSKINEN2001 FARAONE1997 FARRINGTON1989
KRATZER1997 FARRINGTON1989 FERGUSSON1994
RAINE1994 FERGUSSON1994 HELGELAND2005
STEVENSON2001 HERRENKOHL2000 KLEIN1997
LOEBER1991 MCCABE2005
LOEBER1995 MOFFITT2002
LUNTZ1994 RITTER2002
MANNUZZA1998 WHITE2001
MOFFITT2002
PAKIZ1997
SATTERFIELD1997
SOURANDER2006
TREMBLAY1994
WALKER1997
WIESNER2003A
WIESNER2003B
Risk factors Early childhood Childhood factors Adolescent factors
behaviour problems Behaviour problems Behaviour problems
OR = 1.91 (1.66, 2.19) OR = 2.56 (2.10, 3.12) OR = 3.05 (2.56, 3.63)
IQ IQ
OR = 2.00 (1.83, 2.18) OR = 2.12 (1.92, 2.33)
ADHD
OR = 6.22 (4.06, 9.54)
Family factors (maternal Family factors Family factors
rejection, one parent family, Parenting behaviour Combined outcomes
parent separation) OR = 2.64 (1.94, 3.59) OR = 2.50 (1.82, 3.41)
OR = 3.47 (1.80, 6.69)
Parental separation Family antisocial
and/or disharmony behaviour
OR = 2.23 (1.89, 2.64) OR = 2.47 (1.82, 3.35)
Parental separation
and/or disharmony
OR = 2.22 (1.27, 3.85)
Social factors (parent
education, low income)
OR = 2.39 (1.89, 3.04)
Age at 18–32 years 15–32 years 20–32 years
follow- up
92
(OR ⫽ 3.05; 2.56, 3.63). Although the presence of attention deficit hyperactivity disor-
der (ADHD) appeared to be a slightly stronger predictor (OR ⫽6.22; 4.06, 9.54).
There were a variety of family risk factors reported including parenting styles,
parents’ antisocial behaviour and parental disharmony/separation. These effects were
all of a similar magnitude, for example, in the combined family measure in ado-
lescence the OR was 2.50 (1.82, 3.41).
There was slightly less data on social risk factors but in a combined analysis of
factors associated with social deprivation the OR was 2.39 (1.89, 3.04).
5.2.6 Clinical summary
There have been a number of studies assessing risk factors for developing offending
behaviour and adult behaviour problems, and much less on receiving a diagnosis of
antisocial personality disorder. Despite the relatively large number of studies with
long follow-up periods it is only possible to draw very general conclusions regarding
risk factors in this field.
There appears to be a number of factors associated with antisocial personality
disorder including individual child factors (for example, exhibiting behaviour prob-
lems as a child, having a diagnosis or showing symptoms of ADHD), family factors
(for example, parental antisocial behaviour and harsh parenting style) and social
factors (for example, low socioeconomic status). However it should also be reiterated
that although these factors may be associated with a greater risk of developing anti-
social personality disorder, the majority of children with such risk factors will not in
fact develop the disorder in adulthood.
5.3 EARLY INTERVENTIONS
5.3.1 Introduction
The primary aim of early interventions for antisocial and other behavioural problems
and interventions targeting children at risk of developing conduct disorder and antiso-
cial personality disorder in later childhood or adulthood is preventative, and as such,
for the interventions to have any value, mechanisms must be in place to identify those
children, and their families, who might derive benefit from them. The current ‘lingua
franca’ of prevention is based on the work of Gordon (1983), popularised by the
Institute of Medicine report. It differentiates between three strategies of prevention,
each defined by the group they target: (1) universal, (2) selected and (3) indicated.
Universal strategies of prevention are directed at the general population. Where
applicable, the term is to be preferred over the more traditional designation of
‘primary prevention’, because it specifies that the population to which the interven-
tion is applied is not pre-selected. Universal preventive strategies may, and most often
do, identify high-risk populations, but unlike selected intervention programmes, they
do not seek to identify or target individuals within a population based on individual
93
characteristics indicative of high risk. Thus the programme is delivered universally. It

is the population that is at risk (and in these interventions, that risk is generally low),
not the individual within the population.
Selected prevention intervention, as a category, generally overlaps with ‘second-
ary prevention’, although it also includes some interventions that would be considered
primary preventions. These strategies are applied to people who are markedly at risk
of developing the disorder or who show its very early signs. Interventions tend to
focus on the reduction of risk and the strengthening of resilience. Risk is obviously
higher in these selected groups. Often this is a result of a concentration of risk factors
rather than the intensity of any one factor. Hence poverty, unemployment, inadequate
transportation, sub-standard housing, parental mental health problems and marital
conflict may come together to affect a particular child and may be addressed in
preventive programmes. For example, the Elmira Project (described fully below; see
Olds et al., 1997), found that an early intensive nurse home visitation intervention
worked well to prevent child maltreatment in the early years and delinquency at 15
years’ follow-up, but only in the highest risk group. These individuals were identified
by the mother’s age, low socioeconomic status and single parent status.
Indicated intervention, as a category, approximately mirrors the category of tertiary
prevention. These interventions are aimed at specific disorder groups, and they target
people in whom prodromal symptoms of the disorder are already evident but the full
disorder has not yet developed. The treatment of conduct disorder, for example, can be
conceptualised as an indicated intervention for antisocial personality disorder, since
conduct disorder is part of the diagnostic criteria for antisocial personality disorder. It
is often hard to identify an intervention as selected or indicated based on the therapeu-
tic activity that is involved because treatment of conduct disorder can also be regarded
as a selected preventive intervention, since conduct disorder can be a risk factor for anti-
social personality disorder. Cognitive behavioural therapy (CBT), for example, may be
used as a treatment strategy in both selected and indicated prevention interventions for
antisocial behaviour problems. Also, in practice, modern intervention programmes tend
to combine universal, selective and indicated prevention into complex packages (for
example, Conduct Problems Prevention Research Group, 1992).
Behavioural problems affect approximately one in seven children and have in
themselves major societal, economic and personal ramifications (Scott, 2007). If
untreated, up to 50% of preschool children exhibiting behavioural problems will
subsequently develop severe mental health disorders, disorders such as conduct disor-
der and oppositional defiant disorder, and depression (for example, Tremblay et al.,
2004), and the social costs of non-treatment additionally encompass the various
consequences that these disorders entail, such as truancy, family stress, substance
misuse, delinquency and unemployment (Barlow & Stewart-Brown, 2000). The
evidence in support of management approaches to behavioural problems (including
individual psychotherapy and parenting programmes), will be considered in Section 5.4.
Parenting programmes share many elements with prevention programmes in that both
aim to reduce harsh and abusive parenting, increase warm parenting and educate
parents about normal development (for example, Barlow et al., 2005). Given that
treatment services are unlikely to ever be able to meet the needs of all children with
94
behavioural problems, the prevention of these difficulties may be an appropriate first

step in reducing the prevalence and/or severity of antisocial personality disorder.
There have been many thousands of studies evaluating the effectiveness and
benefits of preventive interventions for conduct disorder, although fewer RCTs
(Buckner et al., 1985; Durlak, 1997; Mrazek & Haggerty, 1994; Trickett et al., 1994).
In general, quasi-experimental investigations produce promising findings, but in the
vast majority of cases, such positive results do not stand up to more rigorous RCT
tests (Olds et al., 2007). Even more disappointing is the fact that only a handful of
controlled studies have followed samples for long enough to provide clear indications
of whether antisocial personality disorder may be prevented through early interven-
tion with asymptomatic children.
Current practice
Practitioners in children’s services in the UK have become increasingly interested in
focusing on prevention to address emotional and behavioural problems, including
conduct disorder and related problems, in children and adolescents. A major initia-
tive, the Sure Start Local Programmes, began in 1998 to address the needs of at-risk
children by targeting those children and their families. The current prevailing view is
that this programme has had only limited success, and this is generally attributed to
the fact that the programme was insufficiently targeted on the families with most need
(Belsky et al., 2006). However, as a response to these limitations, changes were made
to the programmes, including specifying services more clearly, placing greater
emphasis on the child’s well-being, focusing on reaching the most vulnerable and
adjusting provision to take into account family disadvantage (Melhuish et al., 2007;
Belsky et al., 2006).
The most recent evaluation suggests these modifications may have had an impact
on outcomes (Melhuish et al., 2008). There were improvements (small-to-medium
effect sizes) in the home learning environment, families accessing services and
reduced parenting risk. However, benefits of the programme for child development
were of a small magnitude. There were no statistically significant effects on the
naming vocabulary sub-scale of the British Ability Scale or on child negative social
behaviour and small statistically significant effects on child positive social behaviour
and independence (Melhuish et al., 2008). There was some evidence that improve-
ments to parenting and family outcomes may in turn lead to improved child outcomes
but this has yet to be conclusively shown.
More recently, there has been an interest in developing and implementing
programmes using the model of those developed by David Olds (see above). Such
programmes, targeting vulnerable parents and children, are currently being carried out
and the feasibility of their use in the UK has been tested (Barnes et al., 2008; see below).
The aim of this review is to assess early interventions for antisocial and other behav-
ioural problems and interventions targeting children at risk of developing conduct disor-
95
der and antisocial personality disorder in later childhood or adulthood. Programmes

under review fall into each of the three main categories of prevention discussed above
(that is, universal prevention, selected prevention and indicated prevention).
this section of the guideline can be found in Table 6. This narrative review is restricted
to studies with follow-up data on participants at a minimum of 15 years of age and a
minimum follow-up period of at least 8 years. Only studies with outcome data on
offending and/or the proportion of participants meeting diagnostic criteria for antiso-
cial personality disorder were included.
5.3.4 Studies considered
The review team conducted a new systematic search for RCTs and quasi-experimen-
tal studies that assessed the benefits and disadvantages of early interventions for
preventing antisocial personality disorder.
Seven trials examining clinical outcomes met the eligibility criteria set by the
GDG (McGauhey et al., 1991; Olds et al., 1997; Schweinhardt et al., 1997; Lally
et al., 1988; Campbell & Ramey, 1994; Reynolds, 1991; Hawkins et al., 1991). All
were published in peer-reviewed journals and books between 1988 and 2007. Fifty-
four studies were excluded from the analysis. The most common reason for exclusion
was an inadequate follow-up period.

clinical evidence
Electronic databases MEDLINE, EMBASE, PsycINFO, Cochrane Library

Date searched Database inception to June 2008; table of contents
June 2008
Study design RCTs and quasi-experimental studies
Patient population Children without behaviour problems followed up until
a minimum of 15 years of age
Outcomes Diagnosis of antisocial personality disorder, offending
96
5.3.5 Clinical evidence for early interventions
Programmes for parents of infants and toddlers

This section reviews studies of interventions for infants and toddlers. Typically they
are targeted at parents of newborn infants and may involve interventions in the ante-
natal period.
The infant health and development programme

Low birth weight is a risk factor for a range of health and developmental problems. In
the early 1980s, McGauhey and colleagues devised a programme consisting of home
visiting, parenting groups and educationally enriched day care, the latter designed to
promote exposure to increasingly complex cognitive tasks and language experiences
(McGauhey et al., 1991). Nine hundred and eighty five low birth weight newborns
were assigned either to this programme or to a control condition. The sample was strat-
ified by birth weight, with a very low birth weight group comprising infants weighing
less than or equal to 2,000 g and a low birth weight group comprising infants weigh-
ing between 2,001 and 2,500 g (Brooks-Gunn et al., 1994). At the most recent follow-
up, when children were 18 years old, approximately two-thirds of the sample was still
adhering to the assessment protocol. An intent-to-treat analysis of data from this
follow-up (McCormick et al., 2006) found the intervention to have beneficial effects
in the 2,001–2,500 g group but not for the lower weight sub-sample. The effects were
mainly on risk behaviours and on various measures of cognitive competence.
Analysis of the costs of the programme indicated it to be a fairly costly interven-
tion, but a cost-benefit analysis has not been conducted since savings achieved by the
programme have not yet been computed (Karoly et al., 2005). The decision to adopt
enhanced care arrangements for low birth weight children should await a comprehen-
sive cost-effectiveness analysis.
Nurse home-visiting programmes

Several studies on nurse home-visiting programmes have reported significant success
in providing effective developmental support. As part of the treatment programme, the
mother’s concerns about being involved in a family intervention are addressed with the
goal of making the treatment programme more acceptable to these mothers and facil-
itating treatment delivery (Olds, 2002). In the best researched programme, the Nurse-
Family Partnership (NFP), the nurse’s work is directed towards a number of aims, such
as improving mothers’ prenatal health-related behaviours (for example, by reducing
mothers’ consumption of cigarettes, alcohol and illegal drugs), enhancing the compe-
tence of early-life care received by the child, and helping parents develop a vision for
their futures, plan subsequent pregnancies, complete their educations, find work, and
enhance their economic self-sufficiency. Fathers, grandmothers, and other concerned
family members or friends are systematically involved in the programme, which also
involves linking families with health and other services. Nurses receive detailed visit-
by-visit programme guidelines to structure their work (Olds et al., 2003).
The NFP model has been tested in three separate RCTs since 1977 (Olds et al.,
1997, 1998, 2002, 2004; Kitzman et al., 1997, 2000; Olds et al., 2002, 2004). The
97
first of these studies, conducted in Elmira, New York, with a sample of 400 low
income, primarily white families, collected follow-up data on families up to the point
the child turned 15 (Olds et al., 1997, 1998). The other two studies, one in Memphis
with a sample of 1,138 low income, primarily African American families (Kitzman
et al., 1997, 2000), and one in Denver with a sample of 735 families, including a large
portion of Hispanics (Olds et al., 2002, 2004), yielded data that provided, though not
unequivocally, additional support for the approach, although neither study reported
follow-up data beyond 6 years. High rates of adherence to the evaluation protocol
were achieved in the studies, with between 81 and 86% of mothers randomised being
successfully followed-up for assessment at 4 to 15 years.
Data from the 15-year follow-up of the Elmira sample (Olds et al., 1997) showed
differences in rates of state-verified reports of child abuse and neglect between treat-
ment and control groups, with families visited by nurses during pregnancy and
infancy being 48% less likely to be identified as perpetrators of child abuse and
neglect; for families with unmarried mothers and for low socioeconomic status fami-
lies, the effect of the programme on maltreatment was increased, but if there was
domestic violence in the household, the effect of the programme on maltreatment was
reduced. There were also fewer arrests, convictions and days of incarceration among
mothers visited by nurses. Importantly for this guideline, young people whose moth-
ers were visited by nurses had 59% fewer arrests and 90% fewer adjudications as
persons in need of supervision for incorrigible bad behaviour. They had fewer
(although not quite significant statistically) convictions and violations of probation
and fewer sexual partners. These and other beneficial effects of the programme were
more notable in the families with the most economically deprived unmarried moth-
ers. The impact of the programme was insufficient to cause changes in teachers’
reports of behaviour problems, school suspensions and parents’ or children’s reports
of major or minor acts of delinquency (Olds et al., 1998).
The Memphis study replicated many of the initial results from the early follow-ups
of the New York project (Kitzman et al., 1997, 2000). In the Memphis study, follow-up
in middle childhood revealed that children in the experimental group had higher intel-
lectual functioning and receptive vocabulary, fewer behavioural problems in the border-
line or clinical range and expressed less aggression and incoherence in response to story
stems compared with children in the control group (Olds et al., 2004). Nurses in the
Denver trial produced effects consistent with the previous two trials (Olds et al., 2002,
2004), and testing at 4-year follow-up showed more advanced language, superior exec-
utive functioning and better behavioural adaptation in those children from the nurse-
visited group whose mothers had low psychological resources than in similar children
from the control group. Notably, paraprofessionals, who were also employed to deliver
the programme, produced about half the effects that nurses were able to deliver.
Based on these three trials, the Washington State Institute for Public Policy esti-
mated that for every family served by nurses, society experiences a $17,000 return on
the investment (Aos et al., 2004). Thus, according to US evaluations, the NFP quali-
fies as an evidence-based community health programme, one that can help transform
the lives of vulnerable mothers pregnant with their first children. A key element of
implementation is enrolling first-time, low-income mothers early in pregnancy.
98
NFP is currently being implemented in ten pilot sites in England (Barnes et al.,
2008). Families have been recruited through NHS systems, with age as the single inclu-
sion criteria for expectant first-time mothers under 20 years (income data not often avail-
able) and a slightly more elaborate set of inclusion criteria applied to expectant first-time
mothers between the ages of 20 and 23 years (not in employment, education or training
and never employed/had no qualifications or no stable relationship with the baby’s
father). In the first year, in all pilot sites, a total of 1,217 young mothers (average age 17.9
years, range 13 to 24 years), or 87% of those eligible for the programme, were success-
fully given treatment. Out of 7,500 nurse visits, a father was present for 1,820.
The first-year report of the evaluating team (Barnes et al., 2008) suggest that
delivery of NFP programmes meeting standards for good treatment fidelity is possi-
ble in the UK. This conclusion was based on the following observations:
1. Appropriate clients have been recruited.
2. NFP was delivered effectively in all sites.
3. NFP was acceptable to UK clients.
4. NFP was acceptable also to fathers and other family members.
5. NFP was acceptable to health visitor practitioners delivering the programme.
6. Organisational infrastructure and support were seen as favourably impacting on
successful delivery.
Initial indicators of effectiveness are promising, with many clients reporting plans
to return to education, closer involvement of fathers with infants, greater confidence
as parents, and engaging in activities with children likely to enhance cognitive and
social development. The data so far collected on the health-related changes that
have already been observed in mothers as a result of treatment participation (for
example, reduced smoking) may reasonably be expected to enhance child health and
reduce negative child outcomes (for example, asthma).
In England, as in the US, NFP appears to function as an important bridge to other
services for the most ‘hard-to reach’. However, the history of prevention efforts make
it clear that the true impact of NFP in the UK cannot be determined until a
randomised UK trial has been conducted.
Preschool programmes for infants and toddlers

This section reviews studies on interventions for infants and toddlers typically at 6
months and up to 5 years of age. These interventions may involve preschool nursery
programmes, educational interventions, and home visiting.
The High-Scope Perry Preschool Project

Of all preschool programmes aimed at disadvantaged children, the Perry Preschool
Project is perhaps the best documented. The programme’s initial goal (Schweinhart
et al., 1993) was to better equip poor minority children for school entry. It focused
on poor families from a high-risk group, had low attrition rates and a follow-up to
age 40. It included 30 weekly special classes each lasting 21/2 hours, as well as weekly
home visits by teachers. Most children participated for 2 years. Active learning and
the facilitation of independence and self-esteem were the focus of the intervention.
Problem-solving skills and task persistence were also strongly encouraged. The
99
teachers were highly skilled, supervised and had a special brief to establish good
home-school integration.
In the study under review, this high-scope intervention was contrasted with two
controls: a behavioural programmed learning approach and a child-centred nursery
programme. The last follow-up occurred when the child reached the age of 40 years.
Up to adolescence, the high-scope group fared best and the programmed learning
group fared worst (Schweinhart et al., 1985). At age 19, only 15% of children in the
high-scope intervention group had been classified as ‘mentally retarded’ whereas
35% of the control group had been so labelled. While over half of the children in the
control groups had been arrested, only 31% of the high-scope group had ever been
detained (RR ⫽ 0.6, 95% CI: 0.38, 0.95). In the follow-up to age 27, lifetime arrest
rates in the high-scope group were half those of the control groups. While minor
offences and drug-related arrests accounted for much of this difference, recidivist
crime was also reduced in the intervention group. Overall, 33% of the control groups
but less than 7% of the high-scope group had been arrested more than five times
(RR ⫽ 0.21, 95% CI: 0.07, 0.58). Similar improvements were observed in teenage
pregnancy rates, high school graduation, home ownership and social benefits. Cost-
benefit analysis revealed that the programme saved the US taxpayer $7 for each dollar
spent. This return was accrued from savings in welfare, social services, legal and
incarceration expenditures (Schweinhart et al., 1993; Schweinhart & Weikart, 1993).
The last follow-up reported progress to age 40, and 112 out of 123 of the adults
who had participated in the study as children were interviewed (Schweinhart, 2007).
Fifty-five per cent of the comparison but only 36% of the programme group had been
arrested at one time (RR ⫽ 0.65, 95% CI: 0.43, 0.98). Forty-eight per cent of the no-
programme group but only 32% of the programme group were arrested for one or
more drug-related crimes (RR ⫽ 0.41, 95% CI: 0.19, 0.85). Significant group differ-
ences in arrests and crimes cited at arrests appeared consistently throughout the study
participants’ lifetime, but significant group differences in conviction and sentences
appeared only at ages 28 to 40. Compared with the no-programme group, the
programme group had significantly fewer members sentenced to prison for felonies
from ages 28 to 40 (RR ⫽ 0.28, 95% CI: 0.09, 0.79).
The Syracuse University Family Development Research Programme

In the Syracuse University Programme the focus was on infant development, home-
care and parenting skills (Lally et al., 1988). Home and day care centre curricula were
designed to foster active initiative and participation, as well as a sense of self-efficacy.
The programme involved the use of sensorimotor and language games to enhance
cognitive development in the infant. In weekly home visits by paraprofessionals, the
role of the parent as primary teacher for the child was emphasised. One learning game
was played at each visit. Support regarding employment, referral, and family relations
was also provided to parents during home visits. Transportation of parents and
siblings to the child care centre for activity meetings was offered. The programme
included high-quality half-day care for infants aged 6 to 15 months and full day care
for those aged 15 to 60 months.
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The sample was of a medium size (n ⫽ 108). There was no randomisation, and
families receiving the intervention were compared with a matched comparison group,
but this group was recruited only when the project children were already 3 years of
age. The mean age of the mothers was 18 years, and more than 85% were single. All
had low incomes and the majority were African-Americans.
The intervention continued until the infant reached the age of 5 years. A quarter
(24%) of the children in the programme did not complete all 5 years of the interven-
tion, and only 50 to 60% completed the follow-up at age 15. At follow-up, girls who
had participated in the programme were found to be doing better in school than
control girls based on grades, attendance, and teacher-rated self-esteem and impulse
control. Boys in the two groups did not differ on measures of school performance, but
for both boys and girls self-regard was more positive in the intervention group than in
the control group, based on self-report measures. The rate of delinquency in the inter-
vention group, calculated from police data, was 6%, whereas in the control group it
was 22% (RR ⫽ 0.27, 95% CI: 0.09, 0.81).
There were also differences in terms of the seriousness of offences and the cost of
crimes committed between the two groups. Lifetime average probation costs were
calculated for the two groups, and were estimated at $186 per child in the interven-
tion group and $1,985 per child in the control group (Lally et al., 1988).
An acknowledgement of the effect of attrition on outcome data would suggest that
these results should be treated with caution. It is reasonable to speculate that delin-
quency rates in families who could not be located for follow-up were quite high,
since, of those families who were located, those with a child involved in juvenile
delinquency proved the most difficult to find.
The Abecedarian Project

The Abecedarian Project was an RCT of early childhood education for healthy infants
from impoverished families living in a small US community in North Carolina
(Campbell & Ramey, 1994). One hundred and eleven infants from low income high-
risk families were recruited to the project between 1972 and 1977 and randomised to
receive the 5-year preschool intervention from infancy to age 5 years. Both groups
received nutritional supplements and social services assistance, with the experimen-
tal group also receiving an educational intervention in a child care centre during the
first 5 years. The focus of the programme was on cognitive and fine motor develop-
ment, social and adaptive skills, language and other motor skills, and the child care
centre also encouraged an unusually high level of parental involvement and offered
social support.
The two groups were re-randomised at entry to kindergarten with half of each
group receiving additional home-based as well as school-based support for the first
3 years (Ramey & Campbell, 1991). Children in the experimental group obtained
higher achievement test scores than control children who had no intervention in either
preschool or kindergarten to second grade. The bulk of this difference appeared to be
because of the preschool intervention. There was a further follow-up at ages 12 to 15
(Campbell & Ramey, 1994), where 80% of those children who were randomly
assigned and 90% of those who received the assigned intervention were tested. The
101
superiority of the experimental group was maintained and in a significant number of

cases it increased. Importantly, the impact of the intervention in kindergarten to
second grade did not endure.
One hundred and five participants of the study were followed up in terms of their
crime records to age 21 (average age 21.4, range 18.7–23.9). Juvenile delinquency statis-
tics were not reported but extensive data concerning criminal history were obtained.
There were no differences between the groups in terms of arrests, regardless of offences,
charges or convictions. The relative risk of arrest after age 16 was 1.10 (95% CI:
0.56–2.19). From this study there is no evidence to suggest that early preschool academic
input addresses functions that come to impact on serious antisocial behaviour.
The Chicago Longitudinal Study of the Child-Parent Center Programme

The Chicago Longitudinal Study investigated the effectiveness of the Child-Parent
Center Programme for more then 1,500 children born in 1979 or 1980. Beginning in
preschool, the programme provided comprehensive services that had been adminis-
tered through the public educational system. The Longitudinal Study of Children at
Risk (Reynolds, 1991) examined the effects of a preschool plus a follow-through
early intervention programme on later school outcomes in a sample of 1,106 econom-
ically disadvantaged families. The intervention had multiple components including
parenting education, volunteering in the classroom, low staff-to-child ratios, home
visitation and health and nutrition services including referrals by programme nurses.
The system of intervention provided a smooth transition to school, it was in place by
the age of 2 years and continued until the early grades. The teachers in the programme
were well trained and well compensated. The programme was 3 hours per day, 5 days
per week during the school year and also included a 6-week summer programme.
Parents were expected to participate in the programme for about half a day per week
through a variety of supported activities providing many opportunities for positive
learning experiences in the school and the home.
The programme group consisted of 989 children and the comparison group of 550
children was drawn from alternative full day kindergarten programmes. There was no
random assignment but some children could be divided into groups that were
involved in child and parent centres in preschool classes, kindergarten and primary
grades. Child and parent centres offered multiple services, emphasising literacy
development, reduced class sizes and considerable parent support and involvement. A
comprehensive analysis of this naturalistic dataset (Reynolds, 1994) indicated that
follow-on from kindergarten and preschool to primary grades was essential for the
achievement test superiority to be maintained to grade 5. Primary grade intervention
(1 to 3 years) resulted in significant improvement in both school achievement and
school adjustment. Participation in the Child-Parent Center preschool intervention
was associated with significantly higher rates of school completion by age 20, lower
rates of juvenile arrests for both violent and non-violent juvenile offences and lower
rate of use of school remedial services (Reynolds et al., 2001).
Extended intervention for 4 to 6 years was linked to significantly lower rates of
remedial education and juvenile arrests for violent offences. One thousand, three
hundred and sixty eight cases, 888 programme cases and 480 controls were available
102
for the 22- to 24-year outcome assessments and more or less the entire sample was
available to obtain crime and employment data. By age 24 years the rate of
incarceration for the comparison group was 25.6% compared with 20.6% in the
preschool programme group (RR ⫽ 0.80, 95% CI: 0.65, 0.98). School-age interven-
tion did not significantly affect incarceration rate (RR ⫽ 1.10, 95% CI: 0.90, 1.34).
Neither preschool (RR ⫽ 0.89, 95% CI: 0.77, 1.03) nor school-age (RR ⫽ 1.10, 95%
CI: 0.90, 1.34) intervention significantly affected overall rates of arrests but preschool
intervention reduced both felony arrests (RR ⫽ 0.78, 95% CI: 0.62, 0.98) and felony
convictions (RR ⫽ 0.79, 95% CI: 0.62, 1.00). Violent crime convictions were also
marginally reduced by preschool intervention (RR ⫽ 0.71, 95% CI: 0.46, 1.10).
Participation in the extended programme was associated with a 32% reduction in rates
of arrests (17.9% versus 13.9%; RR ⫽ 0.77, 95% CI: 0.59, 1.00) and convictions
(RR ⫽ 0.68, 95% CI: 0.45, 1.04) for violence. Also quite pertinent in the present
context, the findings indicated a dramatic reduction in out-of-home placements from
8.4 to 4.5% associated with the preschool intervention (RR ⫽ 0.53, 95% CI: 0.35,
0.81), probably indicative of a reduction in maltreatment.
Regression analyses indicated that the outcomes could be explained by a combi-
nation of increased cognitive skills, positive family support, positive post-programme
school experiences and increased school commitment.
It should also be noted that there is considerable correlational evidence suggest-
ing that early and prolonged low-quality day care represents a risk factor for negative
developmental outcomes (Belsky, 2001; NICHD, 2003; Belsky et al., 2007).
However, there is also evidence from the Canadian longitudinal study (Cote et al.,
2007) that never having non-maternal care is a risk factor for physical aggression for
children of mothers with low educational levels. In this sample (the largest parenting
study yet conducted) early non-maternal care (before 9 months) was associated with
a very slight increase in aggression in mothers of high education level relative to chil-
dren who never had non-maternal care. But this was a small effect when compared
with the increase of risk associated with the absence of non-maternal care in children
of mothers of low education level. The GDG acknowledges that these are complex
issues that are hard to argue from correlational data. However, the GDG wishes to
assert that this does not indicate that good quality non-maternal care for young chil-
dren is necessarily harmful in high risk samples (for example, low educational level)
as this flies in the face of extant data. In terms of creating opportunities for children
of mothers with limited resources, making adequate non-maternal care available is
something that statutory providers should consider delivering.
School-based projects
This section reviews studies of school-age children with a mean age of 7 years.
Typically these interventions consist of a combination of teacher training, parent
training and skills-based interventions for children.
Seattle Social Development Project

This was a classroom-based project beginning in the first grade and ending at sixth
grade (Hawkins et al., 1991, 1992, 1995). The aim of the programme was to strengthen
103
the child’s bonds with their family and school, thus engendering a high level of adher-
ence to the standards set by both. Bonds were conceptualised as positive emotional
feelings towards others (attachment), an investment in a social unit (commitment) and
the adoption of the values of that unit (belief). The interventions included teacher train-
ing, parent training and social and emotional skills development for the child. The
interventions included proactive classroom management, cooperative learning strate-
gies and interactive teaching. There was a component for parents encouraging engage-
ment in the child’s education and workshops in social learning principles of child
behaviour management. There was a problem-solving curriculum as well as drug
refusal skills training. The experimental design involved comparing experimental and
control schools with both random and non-random assignment in a complex design.
Beginning in 1981, the intervention was randomly assigned among grade 1 pupils (7
years of age) in classrooms in eight public schools in high crime areas. These children
were followed prospectively until 1985 when the study was extended to include grade 5
pupils (11 years of age) in ten additional schools. There were ultimately four groups: a
full intervention group (n ⫽ 156; 114 available for follow-up) with an average dose of
4.13 years of intervention exposure; a late intervention group (n ⫽ 267; 256 available for
follow-up) with an average exposure of 1.65 years; a parent training only group
(n ⫽ 141; most recent study did not analyse this group; Hawkins et al., 2005); and a
control group (n ⫽ 220; 205 available for follow-up) who received no intervention.
First results were encouraging (Hawkins et al., 1991; O’Donnell et al., 1995).
Boys in the high-risk sub-sample who participated in the programme had fewer anti-
social peers and appeared to be less likely to be involved in delinquency. In girls the
major benefit was in a reduced likelihood of substance use. At age 18 the intervention
group reported less lifetime violence, less heavy alcohol use, less school misbehav-
iour and improved school achievement compared with controls (Hawkins et al.,
1999). The findings indicated that the postulated mediating variables were indeed
influenced by the programme, even if the impact on delinquency was relatively low.
There was substantial impact on sexual behaviour by age 21 including unplanned
pregnancies and condom use (Lonczak et al., 2002).
Criminal behaviour was assessed in interviews as well as official records (Hawkins
et al., 2005). The full intervention group was less likely to be involved in a high vari-
ety of crime (3% versus 9%, RR ⫽ 0.33, 95% CI: 0.11, 0.93), to have sold illegal drugs
(4% versus 13%, RR ⫽ 0.30, 95% CI: 0.12, 0.74), to have abused substances (74%
versus 82%, RR ⫽ 0.90, 95% CI: 0.80, 1.01) and to have a court record at the age of
21 (42% versus 53%, RR ⫽ 0.79, 95% CI: 0.62, 0.99). Although the effects reaching
statistical significance were limited and the tests were not corrected for the possibility
of Type I error, the full intervention group reported less crime or substance use across
all measures indicating a relatively robust effect from the early intervention.
5.3.6 Clinical evidence summary
Early childhood interventions in the first 5 years of a child’s life tend to show links to
a broad range of positive outcomes. These include higher cognitive skills, school
104
attainment, higher earning capacity, health and mental health benefits, reduced
maltreatment and, significantly for this guideline, lower rates of delinquency and
crime. Early childhood interventions are quite unique in this regard—there are no
other interventions, as far as the GDG was aware, that have generated such a broad
set of positive outcomes. That the impact of interventions should extend beyond
educational performance to criminal behaviour is hardly surprising given the well-
documented relationship between educational outcomes and adult mental health and
social behaviour (for example, Chevalier & Feinstein, 2006). There are also indica-
tions from a number of studies that early interventions are cost effective in providing
both savings and increased well-being that exceed the original investments in the
programmes (Karoly et al., 2005; Reynolds & Temple, 2006; Rolnick & Grunwald,
2003). The economic returns of early childhood interventions exceed cost by an aver-
age ratio of 6 to 1.
In contrast, the evidence for preschool interventions shows more moderate effects
on later offending, with some programmes found not to be effective. A similar picture
emerges with school-based interventions where, again, the evidence for effectiveness
is modest and weaker than earlier interventions. The economic evidence from the US
suggests that, in the long-term, early interventions may result in significant net
savings in terms of reduced welfare payments and crime costs and improved future
earnings (see below).
5.3.7 Health economics evidence
Three studies that evaluated the cost effectiveness of preschool programmes for
infants and toddlers were included in the systematic review of the economic evidence
(Nores et al., 2005; Masse & Barnett, 2002; Reynolds et al., 2002). Details on the
methods used for the systematic search of the economic literature are described in
Chapter 3. Evidence tables for all economic studies included in the guideline
economic literature review are provided in Appendix 14.
A long-term cost-benefit analysis of the High-Scope Perry Preschool Programme
followed up participants as they reached the age of 40 (Nores et al., 2005). The initial
costs of the programme were compared with any long-term benefits in terms of net
changes (versus no intervention) in educational attainment, lifetime earnings, crimi-
nal activity and welfare payments. From various perspectives (the individual partici-
pant, general public and a combination of both), the programme resulted in
significant long-term net benefits of between $49,000 and $230,000 per participant.
Another long-term cost-benefit analysis was conducted for the Abecedarian proj-
ect, which followed up participants at age 21 (Masse & Barnett, 2002). Again, initial
intervention costs were compared with long-term net benefits in terms of future earn-
ings, maternal earnings, education costs, health improvements and welfare use. The
project resulted in significant long-term net benefits of $100,000 per participant.
Finally, a long-term cost-benefit analysis of the Chicago Child-Parent centre
programme was undertaken for participants at age 20 (Reynolds et al., 2002). Initial
intervention costs were compared with long-term net benefits in terms of education
105
costs, child care costs, welfare payments, abuse/neglect costs and justice/crime costs.
Again, from various perspectives (individual participant, taxpayer, and both), the
programme resulted in significant net benefits of between $12,000 and $34,000 per
participant.
5.3.8 From evidence to recommendations
The GDG considered the evidence available on early interventions and noted that the
majority of the interventions were developed in non-UK settings and this raised some
questions about the generalisability of the findings. However, the GDG was
impressed by the consistent impact of these programmes often on quite disadvantaged
families and took the view that the most effective interventions were those targeting
families at risk. Existing evidence from the US indicates that early interventions may
result in great cost savings for the public sector and the children’s families. Early indi-
cations from pilot studies conducted in the UK suggest that it may be feasible to
deliver these programmes in the UK. The GDG also recognised that the focus on
effective identification of at-risk children and their families was central to the effec-
tiveness of these programmes. It was felt that without this focus the impact of the
programmes was likely to be significantly reduced and therefore not cost effective.
Identifying children at risk of developing conduct problems and potentially subsequent

antisocial personality disorder
5.3.9.1 Services should establish robust methods to identify children at risk of
developing conduct problems, integrated when possible with the estab-
lished local assessment system. These should focus on identifying vulner-
able parents, where appropriate antenatally, including:
● parents with other mental health problems, or with significant drug or
alcohol problems.
● mothers younger than 18 years, particularly those with a history of
maltreatment in childhood
● parents with a history of residential care
● parents with significant previous or current contact with the criminal
justice system.
5.3.9.2 When identifying vulnerable parents, take care not to intensify any stigma
associated with the intervention or increase the child’s problems by
labelling them as antisocial or problematic.
Early interventions for at-risk children

5.3.9.3 Early interventions aimed at reducing the risk of the development of
conduct problems, and antisocial personality disorder at a later age, may be
106
considered for children identified to be of high risk of developing conduct

problems. These should be targeted at the parents of children with identi-
fied high-risk factors and include:
● non-maternal care (such as well-staffed nursery care) for children
younger than 1 year
● interventions to improve poor parenting skills for the parents of chil-
dren younger than 3 years.
5.3.9.4 Early interventions should usually be provided by health and social care
professionals over a period of 6–12 months, and should:
● consist of well-structured, manualised programmes that are closely
adhered to
● target multiple risk factors (such as parenting, school behaviour, and
parental health and employment).
5.4 INTERVENTIONS FOR CHILDREN WITH CONDUCT PROBLEMS
5.4.1 Introduction
Current practice
The treatment and management of conduct disorder and related problems in the UK
has significantly expanded in recent years. The NICE technology appraisal on parent-
training programmes (NICE, 2006b) has had a great impact and programmes based
on models developed by Webster-Stratton (Webster-Stratton et al., 1988) among
others, are now widely available in the UK.
In addition, a major pilot programme of multisystemic therapy was developed in
2008, which is currently being rolled out in ten sites across the UK. The outcomes
of this pilot programme, which is subject to a formal evaluation, may have a consid-
erable influence on the development of interventions for conduct disorder.
However, other approaches that may be of potential value, such as individually-
focused interventions including cognitive problem-solving skills, are underdeveloped
in the UK. Similarly other interventions, which are reviewed below, such as func-
tional family therapy, multidimensional treatment foster care, or brief strategic family
therapy, are not widely available in the UK. This is a particular concern because the
primary focus of parent-training programmes is with younger children in the age
range of 4 to 10 years. Evidence-based programmes for adolescents, where parent-
training programmes may be less effective, are not well developed. Beyond main-
stream provision in the NHS by CAMHS, there are also some specialist services (for
example, youth offending teams) where these programmes may serve as effective
preventive interventions for antisocial personality disorder.
In addition, a substantial proportion of young people with conduct problems will
be involved in the criminal justice system where they are likely to receive interven-
tions predominantly based on a cognitive and behavioural approach similar to that
provided for adults (see Chapter 7 for further details).
107
5.4.2 Aim of review and definitions of interventions
The review looked at a wide range of family and individual interventions focused on
children. These interventions were divided into four main categories: child-focused
(skills-based training for children), parent-focused (behaviour management training
for parents), family-focused (seeking to change problem interactions within the
family), and multi-component (targeting the family and the wider social environ-
ment). The intention at the beginning of the guideline development process was to
embed the recommendations in the technology appraisal on parent-training
programmes for children with conduct disorder (NICE, 2006b) in this guideline.
Definitions of child-focused interventions
Cognitive problem-solving skills training

The emphasis of this intervention is on children’s thought processes that impact on
how they behave in interpersonal situations. The intervention includes:
a) teaching a step-by-step approach to solving interpersonal problems
b) structured tasks such as games and stories to aid the development of skills
c) combining a variety of approaches including modelling and practice, role play-
ing, and reinforcement (Kazdin, 2010).
Anger control training

This includes a number of cognitive and behavioural techniques similar to cognitive
problem-solving skills training. However this includes training of other skills such as
relaxation and social skills and a specific focus on managing anger. This is usually
offered to school-age children who are aggressive (Kazdin, 2010).
Social problem skills training

This is a specialist form of cognitive problem-solving skills training that also aims to
modify and expand the child’s interpersonal appraisal processes through developing
a more sophisticated understanding of beliefs and desires in others and to improve the
child’s capacity to regulate their emotional responses (see Fonagy et al., 2002).
Definitions of parent-focused interventions
Parent-training programmes
The main goals of parent-training programmes are to teach the principles of child
behaviour management, to increase parental competence and confidence in raising
children and to improve the parent/carer-child relationship by using good communi-
cation and positive attention to aid the child’s development. These programmes are
structured and follow a set curriculum over several weeks; they are mainly conducted
in groups, but can be modified for individual treatments. Examples of well-developed
programmes are Triple P (Sanders et al., 2000a) and Webster-Stratton
(Webster–Stratton, 1988). The focus is primarily on the main caregiver of the child or
108
young person, although some programmes add a child-directed component

(NCCMH, 2009).
Definitions of family-focused interventions
Structural or systemic family therapy

This is a psychological intervention derived from a model of the interactional
processes in families. The intention is to help participants understand the effects of
their interactions on each other as factors in the development and/or maintenance of
behavioural problems. Additionally, the aim is to change the nature of the interactions
so that families may develop relationships that are more supportive and have less
conflict (NCCMH, 2005a).
Functional family therapy

This is a family-based psychological intervention that is behavioural in focus. The
main elements of the intervention include engagement and motivation of the family
in treatment, problem-solving and behaviour change through parent training and
communication training, and seeking to generalise change from specific behaviours
to have an impact on interactions both within the family and with community agen-
cies such as schools (see for example Gordon et al., 1995).
Brief strategic family therapy

This is a psychological intervention that is systemic in focus and is influenced by
other approaches such as structural family therapy. The main elements of this inter-
vention include engaging and supporting the family, identifying maladaptive family
interactions and seeking to promote new more adaptive family interactions (see for
example, Szapocznik et al., 1989).
Definitions of multi-component interventions
Multisystemic therapy
This is the use of strategies from family therapy and behaviour therapy to intervene
directly in systems and processes related to antisocial behaviour (for example,
parental discipline, family affective relations, peer associations, and school perform-
ances) for children or adolescents (Henggeler et al., 1992).
Multidimensional treatment foster care

Like multisystemic therapy, multidimensional treatment foster care also uses strate-
gies from family therapy and behaviour therapy to intervene directly in systems and
processes related to antisocial behaviour (for example, parental discipline, family
affective relations, peer associations and school performances), but for children or
adolescents in out of home placements. This includes family therapy with the child’s
biological parents and group meetings and other support for the foster parents
(Chamberlain & Reid, 1998).
109

clinical evidence

Date searched Database inception to June 2008
Study design RCT
Patient population Children with conduct problems
Outcomes Behaviour problems, offending
this section of the guideline can be found in Table 7.
The review team conducted a new systematic search for RCTs that assessed the bene-
fits and disadvantages of psychosocial interventions for children, and related health
economic evidence (see Appendices 8 and 11 respectively).
A total of 97 trials relating to clinical evidence met the eligibility criteria set by
the GDG, providing data on 6,665 participants. Of these, one trial was a report from
the Joseph Rowntree Foundation (Scott et al., 2006), one trial was a report of the
Washington Institute of Public Policy (Barnoski, 2004), and 95 were published in
peer-reviewed journals between 1973 and 2008. In addition, 117 studies were
excluded from the analysis. The most common reason for exclusion was lack of rele-
vant outcomes (further information about both included and excluded studies can be
found in Appendix 15).
The included trials involved the following comparisons:
● Parent training compared with control (36 trials)
● Parent training plus an additional intervention for children compared with parent
training (five trials)
5 Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capi-
tal letters (primary author and date of study publication, except where a study is in press or only submit-
ted for publication, then a date is not used). The references for the studies can be found in Appendix 15.
110
● Parent training plus an additional intervention for parents compared with parent
training (six trials)
● Cognitive problem-solving skills training compared with control (five trials)
● Social skills training compared with control (five trials)
● Anger control training compared with control (ten trials)
● Family interventions compared with control (11 trials)
● Multisystemic therapy compared with control (ten trials)
● Multidimensional treatment foster care compared with control (two trials)
● Other multi-component interventions compared with control (four trials)
● Cognitive and behavioural interventions compared with control (eight trials)
● Cognitive and behavioural plus other interventions compared with control
(two trials).
5.4.5 Clinical evidence for interventions targeted at children
in Table 8 and Table 9. Full study characteristics and forest plots can be found in
Appendices 15 and 16 respectively.
For all of these cognitive skills-based interventions there were a variety of
outcomes reported. Wherever possible the primary outcome extracted in the meta-
analysis was from a total behaviour scale. Measures specifically related to the content
of the programme were judged to be less generalisable.
Cognitive problem-solving skills training

There were five trials on cognitive problem-solving skills training. At end of treat-
ment there was a small-to-medium effect favouring cognitive problem-solving skills
training (SMD ⫺0.35; ⫺0.59 to ⫺0.10) and this effect was sustained and actually
improved at 1-year follow-up (SMD ⫺0.42; ⫺0.84 to ⫺0.00).
Anger control
There were ten trials on anger control. Trials that only included interventions for chil-
dren appeared to be more effective (SMD ⫺0.37; ⫺0.58 to ⫺0.16). Interventions that
included a parent intervention in addition to anger control training did not appear to
be effective (SMD ⫺0.06; ⫺0.25 to 0.13).
Social skills training

There were five trials on social skills training. Although the effects were of a similar
magnitude as above (SMD ⫺0.35; ⫺0.73 to 0.03), there was significant heterogene-
ity and confidence intervals were compatible with benefit and no benefit.
111
Table 8: Study information table for trials of interventions targeted at children

and/or for the treatment of conduct problems
Cognitive problem- Social skills Anger control training

solving skills training training versus versus control
versus control control
Total no. of 5 RCTs (N = 274) 5 RCTs (N = 407) 10 RCTs (N = 1,167)
trials (total no.
of participants)
Study ID KAZDIN1989 DEFFENBACHER1996 BARKLEY2000
KENDALL1990 DESBIENS2003 DEFFENBACHER1996
MICHELSON1983 ISON2001 FEINDLER1984
VANMANEN2004 PEPLER1995 LIPMAN2006
WEBSTER- VANMANEN2004 LOCHMAN1984
STRATTON1997 LOCHMAN2002
LOCHMAN2004
OMIZO1988
SHECHTMAN2000
SUKHODOLSKY2000
Diagnosis Conduct disorder and/or Behaviour problems Behaviour problems
behaviour problems
Baseline Diagnosis of conduct Diagnosis of conduct Diagnosis of conduct
severity disorder/oppositional disorder/oppositional disorder/oppositional
defiant disorder: defiant disorder: defiant disorder:
KENDALL1990 ISON2001 BARKLEY2000
VANMANEN2004 VANMANEN2004
WEBSTER- Reported behaviour
STRATTON1997 Reported behaviour problems in the clinical
problems in the clinical range on a behaviour
Reported behaviour range on a behaviour problem scale:
problems in the clinical problem scale: DEFFENBACHER1996
range on a behaviour DEFFENBACHER 1996 LOCHMAN1984
problem scale: ISON2001 LOCHMAN2004
KAZDIN1989
Referred for behaviour Referred for behaviour
Referred for behaviour problems: problems:
problems: PEPLER1995 FEINDLER1984
MICHELSON1983 LIPMAN2006
LOCHMAN2002
OMIZO1988
SHECHTMAN2000
SUKHODOLSKY2000
Treatment length 123 days 219 days 156 days
Length of 1 year No long-term follow-up 1 year
follow-up
Age Range: 4–13 years Range: 6–14 years Range: 5–16 years
112
Table 9: GRADE evidence summary for interventions targeted at children

and/or adolescents with conduct problems (only important outcomes reported)
Cognitive problem-solving skills training compared with control for children and adolescents
with conduct problems
Patient or population: Children and adolescents with conduct problems
Settings: Schools, psychiatric outpatients
Intervention: Cognitive problem-solving skills training
Comparison: Control
Outcomes No. of participants Quality of the Effect size
(studies) evidence (GRADE) (95% CI)
Behaviour 274 丣丣丣丣 SMD –0.35

(end of treatment) (5) high (–0.59 to –0.10)
Behaviour (follow- 93 丣丣丣 SMD –0.42

up) (follow-up: (2) moderate1 (–0.84 to –0.00)
mean 1 years)
1 I-squared ⬎50%
Anger control compared with control for children with conduct problems
Patient or population: Children and adolescents with conduct problems
Settings: Schools
Intervention: Anger control
Comparison: Control
Total behaviour 357 丣丣丣 SMD –0.37

problems (7) moderate1 (–0.58 to –0.16)
1 Possible issue of reactivity of outcome measure
Social skills training compared with control for children and adolescents with behaviour
problems
Patient or population: Children and adolescents with behaviour problems
Settings: Schools
Intervention: Social skills training
Comparison: No treatment
Total behaviour 407 丣丣 SMD –0.35

problems (5) low1,2 (–0.73 to 0.03)
1 I-squared ⬎50%
2 CIs compatible with benefit and no benefit
113
5.4.6 Clinical evidence summary for interventions targeted at children
Interventions that met the criteria of the review were mainly based on cognitive behav-
ioural approaches. Most studies reported small-to-moderate reductions in behaviour
problems. However, there was uncertainty whether the promising results on social
skills and anger control interventions would translate to everyday clinical practice.
5.4.7 Health economics evidence for interventions targeted at children
No evidence on the cost effectiveness of interventions targeted at children was iden-

tified by the systematic search of the literature. Details on the systematic search of the
economic literature are provided in Chapter 3.
There is some evidence for cognitive problem-solving skills training, anger control
and social skills training as interventions targeted at children. The evidence for cogni-
tive problem-solving skills training was slightly stronger with good evidence of effi-
cacy at follow-up in children with relatively severe behavioural problems.
However, the evidence for anger control and social skills training was more
limited with greater variability in effectiveness and questions about the generalisabil-
ity of some outcome measures. The GDG judged that their main value may be in
treating children with residual problems after cognitive problem-solving skills train-
ing, or in treating children when it is not possible to engage the family in treatment.
They may also be effective in providing an alternative where children have not fully
benefited from family interventions.
5.4.9.1 Cognitive problem-solving skills training should be considered for chil-

dren aged 8 years and older with conduct problems if:
● the child’s family is unwilling or unable to engage with a parent-train-
ing programme (see Sections 5.4.14)
● additional factors, such as callous and unemotional traits in the child,
may reduce the likelihood of the child benefiting from parent-training
programmes alone.
5.4.9.2 For children who have residual problems following cognitive problem-
solving skills training, consider anger control or social problem-solving
skills training, depending on the nature of the residual problems.
5.4.9.3 Cognitive problem-solving skills training should be delivered individually
over a period of 10–16 weeks. Training should focus typically on cognitive
strategies to enable the child to:
● generate a range of alternative solutions to interpersonal problems
● analyse the intentions of others
114
● understand the consequences of their actions

● set targets for desirable behaviour.
5.4.9.4 Anger control should usually take place in groups over a period of
10–16 weeks and focus typically on strategies to enable the child to:
● build capacity to improve the perception and interpretation of social cues
● manage anger through coping and self-talk
● generate alternative ‘non-aggressive’ responses to interpersonal problems.
5.4.9.5 Social problem-solving skills training should usually be conducted in
groups over a period of 10–16 weeks. Training should focus typically on
● modify and expand their interpersonal appraisal processes
● develop a more sophisticated understanding of beliefs and desires in others
● improve their capacity to regulate their emotional responses.
5.4.10 Clinical evidence for interventions targeted at parents
There were a large number of studies of parent training, with 36 trials compar-
ing parent training with control. Parent training in behavioural management is
mostly offered in groups but some of the studies were of parents offered this kind of
help individually. There was a small-to-medium effect favouring parent training
(SMD ⫺0.36; ⫺0.51 to ⫺0.22). Heterogeneity was high in the meta-analysis
(I2 ⫽ 63.3%), which is explained to some extent by age and level of risk. A
subgroup analysis of the data suggests that children up to the age of 11 years appear
to be more likely to respond than young people of 12 years or older (children: SMD
⫺0.58; ⫺0.78 to ⫺0.39; young people: SMD ⫺0.32; ⫺0.64 to 0.00) although there
is still overlap in confidence intervals. In addition, a subgroup analysis of the data
comparing studies of children with different levels of risk (participants rated on
factors such as the severity of behaviour problems and socioeconomic status)
showed a smaller effect for studies that included participants at greater risk (high
risk: SMD ⫽ ⫺0.20; ⫺0.33 to ⫺0.07; less risk: SMD ⫽ ⫺0.44; ⫺0.54 to ⫺0.33).
There appears to be good evidence that adding an intervention (usually cognitive
problem-solving skills training) focused on the child adds to the efficacy of parent
training compared with parent training alone (SMD⫽ ⫺0.30; ⫺0.51 to ⫺0.09).
There was less clear evidence for an additional benefit from adjunctive intervention
focused on psychological problems in the parents (for example, CBT for depression
in the mother; SMD ⫽ ⫺0.12; ⫺0.35, 0.11).
It is also important to note that moderators of the effectiveness of parent training have
been identified (Dadds et al., 1987a; Dadds et al., 1987b). More severe and more chronic
antisocial behaviour and comorbidity with other diagnoses predict reduced responsive-
ness to treatment, including dropouts and negative outcomes. However inattention,
115
Table 10: Study information table for trials of interventions targeted at

parents for the treatment of conduct problems
Parent training Parent training + Parent training + Parent training +

versus control additional parent additional child problem-solving
intervention versus intervention versus versus parent
parent training parent training training + education
Total no. of 36 RCTs (N ⫽ 2,509) 5 RCTs (N ⫽ 366) 6 RCTs (N ⫽ 346) 1 RCT (N ⫽ 39)
trials (total no.
of participants)
Study ID ADAMS2001 DADDS1992 BARKLEY 2000 ELIAS2003

BANK1991 IRELAND2003 DISHION1995
BARKLEY2000 SANDERS2000A DRUGLI2006
BEHAN2001 SANDERS2000B KAZDIN1992
BODENMANN2008 WEBSTER- NOCK2005
BRADLEY2003 STRATTON 1994 WEBSTER-
CONNELL1997 STRATTON1997
FEINFIELD2004
GARDNER2006
HUTCHINGS2007
IRVINE1999
JOURILES2001
KACIR1999
KAZDIN1987
LOCHMAN2004
MAGEN1994
MARKIE-DADDS2006
MARTIN2003
NICHOLSON1999
NIXON2003
PATTERSON2007
SANDERS2000
SANDERS2000A
SCOTT2001
SCOTT2006
STEWART-BROWN2007
STOLK2008
STRAYHORN1989
TAYLOR1998
TURNER2006
TURNER2007
WEBSTER-STRATTON1984
WEBSTER-STRATTON 1988
Diagnosis Conduct disorder, Conduct disorder, Conduct disorder, Behaviour problems

oppositional defiant disorder oppositional defiant oppositional defiant
and/or behaviour problems, disorder and/or disorder and/or
offending history behaviour problems behaviour problems
Baseline Diagnosis of conduct Diagnosis of conduct Diagnosis of Not relevant

severity: disorder/oppositional disorder/oppositional conduct disorder/
mean (SD) defiant disorder: defiant disorder: oppositional defiant
disorder:
BARKLEY2000 DADDS1992 KAZDIN1992
CONNELL1997 SANDERS2000B
JOURILES2001 WEBSTER- Reported behaviour
STRATTON1994
Continued
116
Table 10: (Continued)
Parent training Parent training + Parent training + Parent training +

versus control additional parent additional child problem-solving
intervention versus intervention versus versus parent
parent training parent training training + education
KAZDIN1987 Reported behaviour problems in the

NIXON2003 problems in the clinical range on
SCOTT2001 clinical range a behaviour
WEBSTER-STRATTON1984 on a behaviour problem scale:
WEBSTER-STRATTON 1997 problem scale: DISHION1995
SANDERS2000A DRUGLI2006
Reported behaviour problems
in the clinical range on a Referred for
behaviour problem scale: behaviour
BODENMANN2008 problems:
FEINFIELD2004 IRELAND 2003
GARDNER2006
HUTCHINGS2007
IRVINE1999
KACIR1999
LOCHMAN2004
MAGEN1994
MARKIE-DADDS2006
MARTIN2003
PATTERSON2007
SANDERS2000
SANDERS2000A
STEWART-BROWN2007
STOLK2008
Referred for behaviour

problems:
ADAMS2001
BEHAN2001
BRADLEY2003
STRAYHORN1989
TAYLOR1998
TURNER2006
TURNER2007
Offending history:
BANK1991
Treatment Mean: 140 days Mean: 81 days Mean: 150 days 126 days
length
Length of Longest: 3 years Longest: 1 year Longest: 1 year N/A

follow-up
Age Range: 1–18 years Range: 2–9 years Range: 6–14 years Range: 8–11 years
impulsivity and hyperactivity problems increase the size of the response. Extremely high
levels of parental negativity towards the child also reduce responsiveness to the
programme. Low socioeconomic status is associated with more limited outcomes, in
particular if it occurs in combination with social insularity in the family. Maternal
psychopathology, in particular depression and life events, has also been found to reduce
117
Table 11: GRADE evidence summary for trials of interventions targeted at

parents for the treatment of conduct problems (only important outcomes
reported)
Parent training compared with control for children with behaviour problems
Patient or population: Children with behaviour problems
Intervention: Parent training
Comparison: Control
Outcomes No. of Quality of Effect size
participants the evidence (95% CI)
(studies) (GRADE)
Total behaviour problems (end 2509 丣丣丣 SMD −0.36

of treatment) (36) moderate1 (−0.51 to −0.22)
Total behaviour problems
Conduct disorder/oppositional defiant 1403 丣丣丣 SMD −0.26

disorder specific behaviour (end (14) moderate1 (−0.48 to −0.03)
of treatment)
Conduct problems
Behaviour (follow-up) 621 丣丣 SMD −0.29

Total behaviour problems (9) low1,2 (−0.58 to 0.00)
(follow-up: 12 months)
1 I-squared ⬎50%
Components of parent training for children with behaviour problems

Patient or population: Children with behaviour problems
Intervention: Components of parent training
(studies) (GRADE)
Enhanced parent training (behaviour) − 346 丣丣丣丣 SMD −0.30

parent training + child intervention (5) high (−0.51 to −0.09)
versus parent training
Enhanced parent training (behaviour) − 290 丣丣丣 SMD −0.12

parent training + enhancement for (5) moderate1 (−0.35 to 0.11)
parent versus parent training
Enhanced parent training (attrition) − 76 丣丣丣 SMD −0.38

number of sessions attended (1) moderate2 (−0.84 to 0.07)
2 Only one study
118
the effectiveness of parent training. There are also findings indicating that single parent
status, only one parent attending, marital disharmony and maternal insecurity of attach-
ment may undermine progress but many of these associations are not found consistently
across studies. Families with children in the pre-adolescent age group are more likely to
drop out of treatment. The best current evidence-based programmes include modules for
targeting these moderating factors; however, their use is more often supported by corre-
lational rather then RCT data, although RCT data does provide some evidence for limited
interventions such as telephone reminders (Watt et al., 2007). While the present review
does not permit the GDG to make specific recommendations, in general it is desirable to
include additional treatment modules in parent-training programmes that are likely to
prevent the premature termination of treatment.
A number of individual parent training programmes have been evaluated and
found to be effective (Nixon et al., 2003). For younger children (typically between 3
and 6 years) one of the most prominent is parent-child interaction therapy (PCIT) (for
example, Schuhmann et al., 1998). For older children (typically between 5 and 12
years) the parent management training programmes developed in Oregon have also
been shown to be effective (for example, Patterson et al., 1982). However, it is diffi-
cult to make comparisons of effectiveness of group versus individual administration
as it is rarely a subject of tests. Overall effect sizes for individual parent-training
programmes are also confounded by lack of commensurability in terms of the clini-
cal characteristics of the sample.
5.4.11 Clinical evidence summary for interventions targeted at parents
There is a very large evidence base confirming the effectiveness of parent training in
a range of populations in a number of countries. There was significant heterogeneity
in the meta-analysis; subgroup analyses suggest that differences in the ages of the
children and in level of risk may explain, to some extent, some of the inconsistency.
Given the limited evidence for individual parent-training programmes and the lack of
comparators with the stronger evidence base for group-based training programmes
the GDG decided to focus the recommendations on group-based interventions.
There are also a growing number of studies assessing adjuncts to parent training.
The results of the meta-analysis suggest that a cognitive problem-solving intervention
targeted at the child may be effective. Adjuncts targeted specifically at the parent’s
mental health problems were slightly less effective.
5.4.12 Health economic evidence for interventions targeted at parents
The only study identified by the systematic search of economic evidence that met the
inclusion criteria for review was an economic analysis of parent training for children
with conduct disorders (Dretzke et al., 2005) undertaken for the NICE technology
appraisal (NICE, 2006b). According to the technology appraisal, parent training was
found to be cost effective and was recommended for implementation in health and
119
social care settings. Details on the methods used for the systematic search of the
economic literature are described in Chapter 3. Evidence tables for all economic stud-
ies included in the guideline economic literature review are provided in Appendix 14.
Economic analysis in the NICE technology appraisal on parent-training/education

programmes for children with conduct disorders (NICE, 2006b)
The NICE technology appraisal on parent-training/education programmes in the
management of children with conduct disorders (NICE, 2006b) incorporated economic
evidence from two de novo economic models assessing the cost effectiveness of
parent-training/education programmes relative to no active intervention for this
population.
The initial economic analysis (Dretzke et al., 2005) assessed the cost effectiveness
of three parent-training/education programmes differing in the mode of delivery and
the setting: a group community-based programme, a group clinic-based programme,
and an individually delivered, home-based programme. Costs included intervention
costs only; no potential cost savings to the NHS following reduction of antisocial
behaviour in treated children were considered. Total costs of these three types of inter-
ventions were estimated based on a ‘bottom-up’ approach, using expert opinion along-
side information from the literature in order to determine the healthcare resources
required for providing such programmes. Meta-analysis of clinical data had demon-
strated that there was no difference in clinical effectiveness between group-based and
individually delivered programmes. According to the findings of the economic analy-
sis, the group clinic-based programme was the dominant option among the three
parent-training/education programmes, as it provided the same health benefits (same
clinical effectiveness) at the lowest cost (total intervention cost per family was £629
for the group clinic-based programme, £899 for the group community-based
programme, and £3,839 for the individual home-based programme).
Further analyses were undertaken to estimate the cost effectiveness of parent-
training/education programmes assuming various levels of response to treatment and
various levels of improvement in children’s HRQoL. According to this analysis, and
after assuming an 80% uptake of such programmes, the group clinic-based
programme resulted in a cost per responder of £10,060 and £1,006 at a 5% and 50%
success (response) rate, respectively; and a cost per quality-adjusted life year (QALY)
of £12,575 and £3,144 at a 5% and 20% improvement in HRQoL, respectively.
In contrast, provision of an individual home-based programme was demonstrated
to incur a rather high cost of £19,196 per QALY gained, assuming it provided a 20%
improvement in HRQoL. At lower levels of improvement in HRQoL, this figure
became well above the £20,000 per QALY threshold of cost effectiveness set by
NICE (The Guidelines Manual [NICE, 2006a]), rising at approximately £77,000 per
QALY when a 5% improvement in HRQoL was assumed. This means that for fami-
lies where individual parent training is the preferred option, for example in cases
where parents are difficult to engage with, or the complexities of the family’s needs
cannot be met by group-based programmes, the improvement in HRQoL of the child
needs to reach at least 20% for the intervention to meet the cost-effectiveness criteria
set by NICE.
120
The initial economic analysis was based on hypothetical rates of response and
percentages of improvement in HRQoL following provision of parent-training/educa-
tion programmes, as well as on a number of assumptions. Therefore, the results
should be interpreted with caution, as acknowledged by its authors. On the other
hand, it should be noted that estimated figures were conservative, as they did not
include any potential cost savings resulting from reduction in antisocial behaviour in
treated children and associated costs of its management. Despite its limitations, the
analysis demonstrated that group-based parent-training/education programmes for
children with conduct disorders were, as expected, substantially more cost effective
than individually delivered programmes, because the two modes of delivery did not
differ in terms of clinical effectiveness, while the intervention costs of group-based
programmes were spread over a large number of treated families.
The additional economic analysis undertaken to support the NICE technology
appraisal evaluated the cost effectiveness of the three parent-training/education
programmes described above, plus an individually delivered clinic-based
programme, over a time horizon of 1 year. Costs included intervention costs as the
initial analysis, but they also incorporated cost savings to the NHS, education and
social services following provision of parent-training/education programmes to
children with conduct disorders. The analysis modelled three different health states,
that is, normal behaviour, conduct problems and conduct disorders. It was found
that the mean net cost of a parent-training/education programme in improving a
child’s behaviour from conduct disorder to an improved state (either conduct prob-
lems or normal behaviour) was £90 for a group community-based programme,
£1,380 for an individually delivered clinic-based programme, and £2,400 for an
individually delivered home-based programme; the group clinic-based programme
proved to be cost saving overall. These results further support the argument that
group-delivered parent-training/education programmes for children with conduct
disorders are most likely to be cost effective, especially when long-term benefits,
such as the sustained effects of therapy and a reduction in the rates of future offend-
ing behaviour, as well as future cost savings to healthcare, education and social
services, are considered.
The clinical and economic evidence clearly supports the implementation of parent-
training programmes for children with conduct problems. The results suggest that the
likely effect of parent-training programmes will be felt more for younger children.
This suggests that there may be a need to consider augmenting programmes for older
children who have not benefited with cognitive problem-solving skills interventions.
These additional interventions should be focused on the child as there is little
evidence that focusing interventions specifically on the parent is effective. For those
children who have not benefited and/or whose parents have refused treatment, a
second option would be to give consideration to specific individual cognitive prob-
lem-solving skills interventions.
121
5.4.14.1 Group-based parent-training/education programmes are recommended in

the management of children with conduct disorders.6
5.4.14.2 Individual-based parent-training/education programmes are recommended
in the management of children with conduct disorders only in situations
where there are particular difficulties in engaging with the parents or a
family’s needs are too complex to be met by group-based parent-
training/education programmes.7
5.4.14.3 For parents of young people aged between 12 and 17 years with conduct
problems, consider parent-training programmes.
5.4.14.4 Additional interventions targeted specifically at the parents of children
with conduct problems (such as interventions for parental, marital or inter-
personal problems) should not be provided routinely alongside parent-
training programmes, as they are unlikely to have an impact on the child’s
conduct problems.
5.4.14.5 Programme providers should also ensure that support is available to enable
the participation of parents who might otherwise find it difficult to access
these programmes.8
5.4.14.6 Support to enable the participation of parents who might otherwise find it
difficult to access these programmes might include:
● individual parent-training programmes
● regular reminders about meetings (for example, telephone calls)
● effective treatment of comorbid disorders (in particular, attention
deficit hyperactivity disorder in line with ‘Attention deficit hyperactiv-
ity disorder’ NICE clinical guideline 72 [NICE, 2008).
5.4.14.7 It is recommended that all parent-training/education programmes, whether
group- or individual-based, should:9
● be structured and have a curriculum informed by principles of social-
learning theory
● include relationship-enhancing strategies
● offer a sufficient number of sessions, with an optimum of 8–12, to
maximise the possible benefits for participants
● enable parents to identify their own parenting objectives
● incorporate role-play during sessions, as well as homework to be
undertaken between sessions, to achieve generalisation of newly
rehearsed behaviours to the home situation
● be delivered by appropriately trained and skilled facilitators who are
supervised, have access to necessary ongoing professional develop-
6 This recommendation is from NICE technology appraisal 102 (NICE, 2006b).

7 Ibid.
8 Ibid.
9 Ibid.
122
ment, and are able to engage in a productive therapeutic alliance with

parents
● adhere to the programme developer’s manual and employ all of the
necessary materials to ensure consistent implementation of the
programme.
5.4.14.8 Programmes should include problem solving (both for the parent and in
helping to train their child to solve problems) and the promotion of posi-
tive behaviour (for example, through support, use of praise and reward).
5.4.14.9 Programmes should demonstrate proven effectiveness. This should be
based on evidence from randomised controlled trials or other suitable
rigorous evaluation methods undertaken independently.10
5.4.15 Clinical evidence for interventions targeted at families
Eleven trials assessed the effectiveness of family interventions. It appears that
family interventions are more effective than control for reducing both behavioural
problems (SMD ⫽ ⫺0.75; ⫺1.19 to ⫺0.30) and offending (RR ⫽ 0.67; 0.42 to
1.07).
The heterogeneity observed in the risk of re-offending was explained by problems
with therapist competence in BARNOSKI2004. A subgroup analysis found a large
difference when including only competent (RR ⫽ 0.57; 0.42 to 0.78) or non-compe-
tent therapists (RR ⫽ 0.70; 0.36 to 1.38). Data from MCPHERSON1983 was not
included in the analysis as data were not extractable.
The heterogeneity observed in the behaviour scales outcome appeared to be due
to NICKEL2005 and NICKEL2006A. A subgroup analysis showed that substantially
larger effects were reported (SMD ⫽ ⫺1.48; ⫺1.97 to ⫺0.99) in these studies on
reduction in drug use, compared with the other studies’ effects on total behaviour
(SMD ⫽ ⫺0.42; ⫺0.68 to ⫺0.15).
5.4.16 Clinical evidence summary for interventions targeted at families
There appears to be good evidence for the effectiveness of family interventions in a

range of adolescents with conduct problems including offenders. In addition, quasi-
experimental implementation studies confirm the effectiveness of these interventions
in naturalistic settings.
10 Ibid.
123
Table 12: Study information table for trials of family interventions
Family interventions Family interventions Family interventions

versus control for versus control for versus CBT
children and adolescents adolescents at risk
with behaviour problems of re-offending
Total no. of 6 RCTs (N = 177) 2 RCTs 1 RCT (N = 56)
trials (total no. 2 quasi-experimental
of participants) studies (N = 894)
Study ID NICKEL2005 ALEXANDER1973 AZRIN2001
NICKEL2006 BARNOSKI2004
NICKEL2006A GORDON1995
SANTISTEBAN2003 MCPHERSON1983
SAYGER1988
SZAPOCZNIK1989
Diagnosis Conduct disorder, History of offending Conduct disorder
oppositional defiant
disorder and/or behaviour
problems, bullying
Baseline severity: Diagnosis of conduct Not relevant Not relevant
mean (SD) disorder/oppositional
defiant:
SZAPOCZNIK1989
Reported behaviour
problems in the clinical
range on a behaviour
problem scale:
SANTISTEBAN2003

problems:
SAYGER1988
History of bullying:
NICKEL2005
NICKEL2006
NICKEL2006A
Treatment length Mean: 106 days Mean: 92 days Mean: 180 days
Length of Longest: 1 year Longest: 1 year N/A
follow-up
Age Range: 6–18 years Range: 13–17 years Mean: 15 years
124
Table 13: GRADE evidence summary for family interventions (only important
outcomes reported)

(studies) (GRADE)
Behaviour scales (end of treatment) 237 丣丣丣 SMD −0.75

(follow-up: mean 6 months) (6) moderate1 (−1.19 to −0.3)
Risk of re-arrest 613 丣丣丣 RR 0.57

(follow-up: 18 months - 5 years) (3) moderate2 (0.42 to 0.77)
(BARNOSKI2004 participants
treated by competent therapists)
Risk of re-arrest 819 丣丣丣 RR 0.67

(follow-up: 18 months - 5 years) (3) moderate1,2 (0.42 to 1.07)
(BARNOSKI2004 participants treated
by both competent and
non-competent therapists)
1 I-squared ⬎50%
2 Quasi-experimental studies
5.4.17 Health economic evidence for interventions targeted at families
Systematic literature review

Two studies from the US were identified that considered the cost effectiveness of
interventions targeted at families (Barnoski, 2004; Crane et al., 2005). The study by
Barnoski (2004) evaluated functional family therapy for moderate to high-risk
juvenile offenders (13 to 17 years). Costs of the intervention were compared with
differences in recidivism rates and resulting criminal justice costs versus no
intervention. Overall, functional family therapy resulted in significant net savings due
to lower rates of recidivism compared with no intervention. The study by Crane and
colleagues (2005) was a simple retrospective cost analysis of in-home or in-office
family therapy versus no treatment for youths with conduct disorder. Over 30 months
both interventions resulted in significant net savings (p ⬍ 0.0001) in terms of reduced
future healthcare spending. No studies were identified that considered the cost effec-
tiveness of family interventions in the UK. Details on the methods used for the
systematic search of the economic literature are described in Chapter 3. Evidence
tables for all economic studies included in the guideline economic literature review
are provided in Appendix 14.
Economic modelling
Objective
The guideline systematic review and meta-analysis of clinical evidence demonstrated
that provision of functional family therapy to families of adolescents with a history of
125
offending behaviour significantly reduces the rates of future reconviction. Offending

behaviour and subsequent reconviction lead to substantial costs, not only to the crim-
inal justice system but also to victims and society in general. A cost analysis was
undertaken to assess whether the costs to the NHS of providing functional family
therapy to families of adolescents at risk for offending behaviour are offset by future
cost savings resulting from reduction in offending behaviour (and subsequent recon-
viction rates) in young offenders.
Methods
Intervention examined Functional family therapy is a short-term intervention: on
average 8 to 12 sessions are needed for mild problems and up to 30 hours of direct
service (for example, clinical sessions, telephone calls and meetings involving
community resources) for more difficult cases. For most participants, sessions are
spread over a 3-month period. Functional family therapy programmes have been
successfully delivered in home-based, clinic-based and school-based settings. In
Washington where functional family therapy was evaluated, trained therapists had
caseloads of 10 to 12 families (Barnoski, 2004). The effectiveness of therapy in
reducing recidivism may be directly related to the competence of the therapist
(Barnoski, 2004). Implementation of functional family therapy, therefore, focuses
particularly on developing therapist competence rather than simply teaching skills.
Costs considered in the analysis A simple economic model was developed to esti-
mate the net total costs (or cost savings) associated with provision of functional
family therapy to families of adolescents at risk for offending behaviour. Adolescents
with conduct disorder and/or offending behaviour have been found to incur substan-
tial costs to the health, educational, social and criminal justice services. Scott and
colleagues (2001a) estimated the public costs incurred by children with conduct
disorder from 10 years of age through adulthood (by age 28) in the UK. The authors
reported a total cost of £70,000 per person diagnosed with conduct disorder in child-
hood, compared with £7,000 for a person without any conduct problems. Criminal
justice system services bore most of this cost (64%), whereas the cost to educational
services reached 18% of the total cost. Foster and residential care costs amounted to
11% of the total cost, and social benefits to another 4%. Finally, the cost to the health-
care services was only 3% of the total cost incurred by individuals with conduct disor-
der from childhood through adulthood.
NICE recommends that economic analyses of healthcare interventions adopt a
NHS and personal social services (PSS) perspective (NICE, 2006a). However, in the
case of adolescents with offending behaviour, the majority of incurred costs falls on
the criminal justice system, education services, social and other public services.
Only a small minority of costs is covered by the NHS and PSS perspective. For this
reason, the economic analysis adopted a broader perspective than that of the NHS
and PPS, including any costs to public services for which appropriate information
was available.
The study by Scott and colleagues (2001a) illustrated the variety and magnitude
of costs associated with conduct disorder and, more broadly, offending behaviour;
126
nevertheless, little evidence exists about the potential reduction (or increase) in
specific cost components resulting from provision of functional family therapy to
families of young offenders. Clinical evidence has demonstrated that functional
family therapy significantly reduces reconviction rates, and subsequently costs
relating to crime. It is likely that provision of functional family therapy, by reduc-
ing offending behaviour, also reduces other types of cost, such as health and social
care costs, as well as costs to the educational services. However, no appropriate
relevant data that could inform this economic analysis were identified in the
literature. For this reason, the analysis has considered only intervention costs (that
is, costs of providing functional family therapy) and costs related to crime/offend-
ing behaviour of adolescents. All other categories of costs to the public sector, such
as health and social care costs and costs to educational services, were conserva-
tively assumed to be the same for adolescents receiving functional family therapy
and for those not receiving the intervention, and were subsequently omitted from
the analysis. This is acknowledged as a limitation of the economic analysis.
However, costs relating to crime constitute the most substantial part of the costs
incurred by young offenders; therefore, the economic analysis has probably consid-
ered the majority of costs associated with providing functional family therapy to
families of young offenders.
Model input parameters
Clinical efficacy of functional family therapy and baseline re-offending rate in

juvenile offenders
Clinical data on re-arrest rates (reflecting re-offending behaviour) associated with
provision of functional family therapy were derived from three studies (ALEXAN-
DER1973; BARNOSKI2004; GORDON1995). Meta-analysis of these data under-
taken for the guideline showed that providing functional family therapy to families of
adolescents with offending behaviour reduced the rate of re-arrest compared with
usual care/no treatment. Of the three clinical studies included in the meta-analysis,
BARNOSKI2004 reported results for participants treated by both competent and non-
competent therapists, and separate results for a subgroup of participants treated by
competent therapists only. Therefore, two separate guideline meta-analyses were
performed: one including all efficacy data reported in the relevant literature, and one
sub-analysis including efficacy data on families treated by competent therapists only.
The results of the meta-analysis indicated that provision of functional family therapy
by both competent and non-competent therapists reduces the re-arrest rates in adoles-
cents with offending behaviour, but these results were non-significant at the 0.05 level
(mean RR of re-arrest of functional family therapy versus control: 0.67; 95% CI: 0.42
to 1.07). In contrast, when only data on competent therapists were considered, func-
tional family therapy was shown to significantly reduce the re-arrest rates in juvenile
offenders (mean RR of re-arrest of functional family therapy versus control: 0.59;
95% CI: 0.43 to 0.79). Details on the clinical studies considered in the economic
analysis are available in Appendix 15. The forest plots of the respective meta-analy-
ses are provided in Appendix 16.
127
The baseline re-offending rate for adolescents with previous offending behaviour
was taken from a national report containing 12-month data on re-offending for
adolescents aged 10 to 17 years released from custody (either from prison, secure
training centres or secure children’s homes) or commencing a non-custodial court
disposal, or given an out-of-court disposal (either a reprimand or final warning) in
England and Wales in 2006 (Ministry of Justice, 2008b). According to this document,
the re-offending rate in this population was 38.7% over 12 months. This rate was
defined by the number of offenders in the cohort re-offending at least once during the
12-month follow-up period, where the offence resulted in a conviction at court or an
out-of-court disposal. The 12-month rate of adolescent re-offending following provi-
sion of functional family therapy in the economic analysis was calculated by multi-
plying the estimated RR of re-arrest of functional family therapy versus control by the
baseline re-offending rate.
Intervention costs (costs of providing functional family therapy)

In order to calculate total intervention costs, relevant resource use was estimated and
combined with respective unit costs. Resource use estimates were based on informa-
tion provided in the clinical studies included in the guideline systematic review.
According to these estimates, functional family therapy consisted of 12 sessions over
a 90-day period lasting 1.5 hours each, delivered to groups of ten families of adoles-
cents with offending behaviour.
The unit cost of therapists providing functional family therapy was estimated to
be similar to that of clinical psychologists (Band 7). The national unit cost of clin-
ical psychologists has been estimated at £67 per hour of client contact in 2006/07
prices (Curtis, 2007). This estimate was based on the mid-point of Agenda for
Change salaries Band 7 of the April 2006 pay scale according to the National
Profile for Clinical Psychologists, Counsellors and Psychotherapists (NHS, 2006).
It includes salary, salary on-costs, overheads and capital overheads but does not
take into account qualification costs as the latter are not available for clinical
psychologists.
Based on the above resource use estimates and the unit cost of clinical psycholo-
gists, the cost of providing the Reasoning and Rehabilitation programme was esti-
mated at £121 per adolescent with offending behaviour in 2006/7 prices.
Costs of adolescent offending behaviour

In order to estimate the annual cost resulting from repeat of offending behaviour by
adolescent offenders, three types of data are needed:
● proportion of different types of offences committed by adolescent re-offenders
● costs associated with each type of offence
● number of offences per adolescent re-offender per year.
Data on the proportion of different types of offences committed by adolescent re-
offenders in England and Wales were derived from a national report published by the
Ministry of Justice (2008b). The same document reported that the number of offences
per juvenile re-offender were 3.181 over 12 months.
128
Regarding costs associated with each type of offence committed by adolescent

offenders, these were taken from a variety of sources:
● Costs of offences against individuals and households, such as violence including
homicide, sexual offences, theft including stealing vehicles and stealing from
vehicles, robbery, criminal and malicious damage and domestic burglary were
taken from Home Office data (Dubourg & Hamed, 2005). This report estimated
a wide range of costs associated with crime, including costs incurred in anticipa-
tion of crime, such as security expenditure and insurance administration, costs
directly resulting from crime, such as stolen or damaged property, lost output,
emotional and physical impact on victims, health services to victims, other
victim services, as well as costs to the criminal justice system, including police
services.
● Costs of non-domestic burglary and costs of fraud and forgery were also based on
Home Office data (Brand & Price, 2000). Reported costs included the same cost
elements as described above.
● The cost of motoring offences (excluding thefts from or of vehicles and drink
driving) was assumed to correspond to the cost of accidents leading to damage
(but not injury) as reported by the Department of Transport (2007). This cost
included police costs, costs relating to insurance and administration services, and
costs resulting from property damage.
● The cost of drugs import/export/production and supply was derived from Home
Office estimates of the average cost of arrest for drugs possession and supply
(Godfrey et al., 2002). The same report suggested that the cost of arrest for
possession of drugs (but not supply) was equal to the general cost of arrest. The
latter cost was reported in the same document and was assumed to reflect the cost
associated with arrest for drug possession and small-scale supply.
● The costs of public order or riot, soliciting or prostitution, handling, and abscond-
ing or bail offences were (rather conservatively) assumed to correspond to the cost
of general arrest, as reported in Godfrey and colleagues (2002). The costs of drink
driving and other, not specified, offences were based on assumptions.
Costs reported in the literature were uplifted to 2007 prices using the Retail Prices
Index (Office for National Statistics, 2008). The cost per offence committed by
adolescent re-offenders was estimated as the mean cost of all offences weighted by
the proportion of offences committed on average by an adolescent re-offender. Table 14
shows the percentage of offences committed by adolescent re-offenders, the cost of
each type of offence as estimated in the literature, and the weighted average cost per
offence committed by adolescent re-offenders.
The average cost per offence committed by adolescent re-offenders was estimated
at £3,639. Since this population has been found to commit 3.181 offences over 12
months (Ministry of Justice, 2008b), the 12-month cost associated with offending
behaviour is £11,576 per juvenile re-offender.
Time horizon of the analysis Of the three studies included in the relevant guideline
meta-analysis of functional family therapy clinical data, two studies had a time
129
Table 14: Percentage and costs of offences committed by adolescent

re-offenders
Type of offence Percentage1 Cost Source of cost

(£, 2007
prices)
Violence (serious) 0.48 45,686 Dubourg & Hamed, 2005
Violence (non serious) 19.80 9,180 Dubourg & Hamed, 2005
Robbery 2.61 8,298 Dubourg & Hamed, 2005
Public order or riot 9.90 1,671 Godfrey et al., 2002
Sexual 0.22 35,825 Dubourg & Hamed, 2005
Sexual (child) 0.08 35,825 Dubourg & Hamed, 2005
Soliciting or prostitution 0.00 1,671 Godfrey et al., 2002
Domestic burglary 2.89 3,724 Dubourg & Hamed, 2005
Other burglary 2.87 3,373 Brand & Price, 2000
Theft 13.65 722 Dubourg & Hamed, 2005
Handling 1.50 1,671 Godfrey et al., 2002
Fraud and forgery 0.84 1,874 Brand & Price, 2000
Absconding or bail 4.59 1,671 Godfrey et al., 2002
offences
Taking and driving away 3.66 4,715 Dubourg & Hamed, 2005
and related offences
Theft from vehicles 1.43 978 Dubourg & Hamed, 2005
Other motoring offences 10.72 1,840 Department of Transport, 2007
Drink driving 0.65 200 Assumption
Criminal or malicious 13.76 987 Dubourg & Hamed, 2005
damage
Drugs import/export/ 0.29 4,308 Godfrey et al., 2002
production/supply
Drugs possession/small 4.51 1,671 Godfrey et al., 2002
scale supply
Other 5.54 1,500 Assumption
TOTAL 100.00 3,639†
1 Source: Ministry of Justice, 2008b; †Total weighted cost (100.00)
130
horizon of 18 months (ALEXANDER1973 and BARNOSKI2004, with a total study

population of 765 adolescents) and one study had a time horizon of 5 years
(GORDON1995, with a study population of 54 adolescents). For the base-case
analysis, a 2-year time horizon was chosen. However, time horizons up to 5 years
were tested in sensitivity analysis, to explore the magnitude of potential savings
resulting from provision of functional family therapy.
Discounting Costs incurred beyond 12 months were discounted at an annual rate of

3.5%, as recommended by NICE (NICE, 2006a).
Table 15 provides all input parameters utilised in the base-case analysis of the
economic model of functional family therapy for families of adolescents at risk for
offending behaviour.
Sensitivity analysis One- and two-way sensitivity analyses were undertaken to

explore the robustness of the results under the uncertainty characterising some model
input parameters. The following scenarios were tested in sensitivity analysis:
● Use of the 95% CIs of the RR of re-arrest of functional family therapy versus
control.
● Exclusion of data on adolescents seen by non-competent therapists (that is, using
a mean RR of re-arrest of functional family therapy versus control 0.59 with 95%
CIs 0.43 to 0.79).
Table 15: Input parameters utilised in the economic model assessing the net
costs (or savings) resulting from provision of functional family therapy to
families of adolescents at risk for offending behaviour
Input parameters Value Source of data - comments

RR (95% CIs) of functional 0.67 (0.42 to 1.07) Guideline meta-analysis
family therapy versus
control – all therapists
Baseline re-offending rate of 38.7% Ministry of Justice, 2008b
adolescent re-offenders
(12 months)
Intervention cost per £121 Based on 12 sessions lasting
adolescent 1.5 hours each, delivered to
groups of 10 families
Weighted average cost per £3,639 See Table 14
offence committed by
adolescent re-offenders
Number of offences per 3.181 Ministry of Justice, 2008b
adolescent re-offender
(12 months)
Annual discount rate 0.035 NICE, 2007
131
● Increase of intensity of functional family therapy; 18 sessions of 2 hours each

were assumed.
● Reduction in the baseline re-offending rate for adolescents with previous offend-
ing behaviour; an annual rate of 20% was tested.
● Extension of the time horizon of the analysis beyond 2 years; limited evidence
suggested that the effect of functional family therapy in reducing the re-arrest
rates in adolescents with a history of offending behaviour remained over 5 years
(GORDON1995). Therefore, potential net savings accrued over 3, 4 and 5 years
following provision of functional family therapy were estimated. This scenario
was combined with all other scenarios described above.
● Potential net savings accrued over 3, 4 and 5 years were also estimated assuming
that the effect of the intervention was reduced over time; in this scenario the RR
of functional family therapy versus control was multiplied by a factor of 1.15 for
every year after 2 years from initiation of the intervention, to capture this assumed
decline in the clinical effect over time, until functional family therapy had no
beneficial effect over control (that is, until RR became 1).
● Reduction in the annual cost of offending behaviour per re-offender: a conserva-
tive figure of £1,000 per offence and two offences per re-offender per year were
simultaneously assumed, resulting in a total annual cost of offending behaviour of
£2,000 (instead of £11,576, which was the respective estimate used in base-case
analysis) – therefore, any savings expected from reduction in re-offending follow-
ing provision of functional family therapy would be much lower under this
hypothesis.
● Simultaneous use of an RR of functional family therapy versus control of 0.79
(which was the upper 95% CI in the sub-analysis that included competent thera-
pists) and a conservative annual cost of offending behaviour per adolescent re-
offender of £2,000, as estimated in the previous scenario.
● Combination of alternative time horizons between 2 and 5 years with all other
scenarios described above.
Results
Base-case analysis The reduction in re-offending rates achieved by provision of func-
tional family therapy to families of adolescents at risk for re-offending yielded cost-
savings equalling £2,908 per adolescent with offending behaviour over the 2 years of
the analysis. Providing functional family therapy incurs a cost of £121 per adolescent,
but this cost was offset by the substantial savings from reduction in offending behav-
iour. Overall, functional family therapy resulted in a net saving of £2,787 per adolescent
with offending behaviour over 2 years. Full results of the base-case analysis are reported
in Table 16.
Sensitivity analysis Results of the cost analysis were robust under the different
scenarios examined in sensitivity analysis. Under all scenarios, provision of func-
tional family therapy resulted in overall net savings even under a time horizon of 2
years, with the only exception being the use of the upper 95% CI of RR of re-arrest
of functional family therapy versus control taken from meta-analysis of data including
132
non-competent therapists (this upper 95% CI had a value of 1.07 as results were non-
significant at the 0.05 level). Under the most optimistic scenario of a lasting effect of
5 years, and using the lower 95% CI of the RR of re-arrest of functional family ther-
apy versus control, functional family therapy resulted in net savings of £12,021 per
adolescent with offending behaviour. Full results of sensitivity analysis are presented
in Table 17.
Table 16: Results of economic analysis assessing the net costs (or savings)
resulting from provision of functional family therapy to families of adolescents
at risk for offending behaviour
Costs per adolescent Functional family Control Difference

(2007 prices) therapy
Functional family £121 0 £121
therapy cost
Cost of offending £5,901 £8,809 − £2,908
behaviour
Total cost £5,922 £8,809 − £2,787
Table 17: Results of sensitivity cost analysis of provision of functional family

therapy to families of adolescents at risk for offending behaviour
Net cost at different time horizons (2007 prices)

Scenario tested 2 years 3 years 4 years 5 years
Meta-analysis of data from all therapists
• Mean RR − £2,787 − £4,166 − £5,499 − £6,788
• Lower 95% CI − £4,988 − £7,414 − £9,757 − £12,021
• Upper 95% CI £737 £1,030 £1,313 £1,586
Meta-analysis of data from competent therapists
• Mean RR − £3,491 − £5,205 − £6,862 − £8,463
• Lower 95% CI − £4,900 − £7,284 − £9,587 − £11,812
• Upper 95% CI − £1,729 − £2,607 − £3,456 − £4,276
Increase in intensity of functional family therapy − £2,665 − £4,046 − £5,379 − £6,667
Baseline adolescent re-offending rate of 20% − £1,382 − £2,095 − £2,784 − £3,450
Increase in RR by 15% annually after 2 years − £2,786 − £3,746 − £4,206 − £4,206
Annual cost of offending behaviour of £1,000 − £131 − £250 − £365 − £476
Use of upper 95% CI of RR of competent ⫺ £39 ⫺ £115 ⫺ £188 ⫺ £259

therapists plus annual cost of offending
behaviour of £1,000
133
Discussion – limitations of the analysis

The results of the economic analysis suggest that provision of functional family ther-
apy to families of adolescents with a history of offending behaviour is likely to be
cost saving from a broad economic perspective in the UK. Intervention costs were
shown to be offset by savings from a reduction in the rates of re-arrest. The results
were robust under the majority of scenarios examined in sensitivity analysis. The
only exception was the use of results of meta-analysis that included data on both
competent and non-competent therapists; in this case, results were statistically
insignificant and use of the upper 95% CI of the RR of re-arrest of functional family
therapy versus control did not produce cost savings. However, given that in the UK
both clinical psychologist and family therapist training has moved towards compe-
tence-based models of training (Roth & Pilling, 2008), it is unlikely that those
deemed not sufficiently competent would be involved in implementation of func-
tional family therapy. Furthermore, under the accreditation and audit processes used
in the National Offender Management Service (NOMS), poor therapists or
programme tutors would not be allowed to deliver such programmes (National
Offender Management Service, 2008).
Adolescents with offending behaviour incur significant costs to health, social,
educational and criminal justice services, as well as to their families (Scott et al.,
2001a). The economic analysis considered only intervention costs and costs relating
to offending behaviour owing to lack of evidence for a difference in other types of
costs between functional family therapy and no treatment. Cost data on offending
behaviour were derived from several published sources reporting UK data and
included, in most cases, a wide range of costs, such as costs incurred in anticipation
of offending behaviour (for example, security expenditure), costs directly resulting
from offending (such as costs of stolen or damaged property and emotional and phys-
ical impact on victims), costs of offering health and other services to victims, as well
as costs to the criminal justice system. Although it is acknowledged that omission of
educational, social and other healthcare costs constitutes a limitation of the analysis,
existing evidence indicates that costs of offending behaviour are probably the most
significant costs incurred by adolescents with offending behaviour. Besides, it is
likely that functional family therapy, by improving adolescent behaviour, also reduces
other costs incurred by adolescent offenders, such as costs falling on special educa-
tional services. If this is true, then the economic analysis has only underestimated the
net savings gained from functional family therapy. Furthermore, some of the cost data
on offending behaviour that were utilised in the economic analysis comprised crimi-
nal justice system costs only. The healthcare costs and emotional distress of victims,
the financial and economic burden to the families of both victims and offenders, and
the feelings of fear and insecurity in anticipation of crime were not considered in most
documents reporting cost data on offending behaviour. Had these factors been consid-
ered, the cost savings from reduction in offending behaviour might be greater than
figures reported in the analysis.
Sensitivity analysis showed that even if a more intensive functional family ther-
apy programme were implemented, the intervention would still be cost saving. More
intensive functional family therapy programmes than this described in the base-case
134
economic analysis may be needed in more complex cases, and this would result in
higher intervention costs. On the other hand, it has been shown that adolescents with
a more severe history of offending behaviour are characterised by higher rates of re-
offending and higher numbers of offences per year (Ministry of Justice, 2008b).
Therefore, a reduction in offending behaviour in this group of adolescents would lead
to greater cost savings, compared with adolescents with mild offending behaviour.
Consequently, complex cases, which might require more intensive treatment, are
likely to produce greater cost savings, offsetting the higher intervention costs.
The time horizon of the analysis was 2 years, according to available evidence.
However, limited evidence indicates that the beneficial effect of functional family
therapy may last for longer time periods (over 5 years following provision of the ther-
apy). Consequently, net savings from functional family therapy estimated in base-
case analysis are rather conservative; greater cost savings may be realised if the effect
of functional family therapy lasts longer than 2 years.
Conclusion
Overall, and despite conservative estimates utilised in the economic model, provision
of functional family therapy to families of adolescents at risk for offending behaviour
is likely to be cost-saving. Given that functional family therapy is also an effective
intervention that improves adolescent offending behaviour, functional family therapy
is likely a cost-effective intervention.
The evidence suggests that a range of family interventions, including systemic and
strategic family therapy, may be effective for children with conduct problems and
conduct disorder. Interventions such as functional family therapy may be particularly
effective for older adolescents for whom the evidence for the efficacy of parent-train-
ing programmes is weak, and are also likely to be cost effective. The evidence
suggests that functional family therapy, and potentially brief strategic family therapy,
should become viable alternatives to parent training for older adolescents. This
requires individual clinicians to consider the relative benefits of the two, including
child and adult preferences.
5.4.19.1 If the parents are unable to or choose not to engage with parent-training
programmes, or the young person’s conduct problems are so severe that they
will be less likely to benefit from parent-training programmes, consider:
● brief strategic family therapy for those with predominantly drug-
related problems
● functional family therapy for those with predominantly a history of
offending.
135
5.4.19.2 Brief strategic family therapy should consist of at least fortnightly meet-
ings over a period of 3 months and focus on:
● engaging and supporting the family
● engaging and using the support of the wider social and educational
system
● identifying maladaptive family interactions (including areas of power
distribution and conflict resolution)
● promoting new and more adaptive family interactions (including open
and effective communication).
5.4.19.3 Functional family therapy should be conducted over a period of 3 months
by health or social care professionals and focus on improving the interac-
tions within the family, including:
● engaging and motivating the family in treatment (enhancing perception
that change is possible, positive reframing and establishing a positive
alliance)
● problem-solving and behaviour change through parent-training and
communication training
● promoting generalisation of change in specific behaviours to broader
contexts, both within the family and the community (such as schools).
5.4.20 Clinical evidence for multi-component interventions
Some researchers have combined two or more psychological and/or psychosocial
interventions, provided concurrently or consecutively, in an attempt to increase the
effectiveness of the intervention. For example, a course of family intervention may be
combined with a module of social skills training. The combinations are various and
thus these multi-modal interventions do not form a homogenous group of interven-
tions that can be analysed together.
Ten trials on multisystemic therapy that met the inclusion criteria for the review
were included. There was significant heterogeneity for most outcomes; however,
there was consistent evidence of a medium effect on reduction in offending outcomes
including number of arrests (SMD ⫺0.44; ⫺0.82 to ⫺0.06) and being arrested (RR
0.65; 0.42 to 1.00).
The main source of heterogeneity was LESCHIED2002, which found no differ-
ence between multisystemic therapy and treatment as usual on all primary outcomes.
A possible explanation is that the majority of trials of multisystemic therapy were
conducted in the US by the founders Henggeler and colleagues, whereas
LESCHIED2002 is a Canadian trial undertaken independently from the founders of
multisystemic therapy. However, a study by OGDEN2004 on a Norwegian sample,
which was also conducted independently, found positive effects for multisystemic
therapy for slightly different outcomes.
136
Table 18: Study information table for trials of multi-component interventions

for adolescents at risk of offending
Multisystemic Multidimensional Other multi-component

therapy versus treatment foster interventions
control care versus control versus control
Total no. of 10 RCTs 2 RCTs 3 RCTs
trials (total no. (N = 1,642) (N = 166) (N = 265)
of participants)
Study ID BORDUIN1995 CHAMBERLAIN1998 BARRETT2000 (family
BORDUIN2001 CHAMBERLAIN2007 therapy + anger control +
HENGGELER1992 problem solving skills)
HENGGELER1997 CAVELL2000 (problem
HENGGELER1999 solving skills +
HENGGELER2006 mentoring)
LESCHIED2002 FRASER2004 (family
OGDEN2004 therapy + parent training +
ROWLAND2005 social skills training)
TIMMONS-
MITCHELL 2006
Diagnosis Young people with an Young people with an Oppositional defiant
offending history offending history disorder and/or behaviour
problems; young people
with an offending history
Baseline Not relevant Not relevant Diagnosis of conduct
severity: mean disorder/oppositional
(SD) defiant disorder:
BARRETT2000
Reported behaviour
problems in the clinical
range on a behaviour
problem scale:
CAVELL2000

problems:
FRASER2004
Treatment 128 days 174 days 208 days
length
Length of Longest: 4 years Longest: 2 years Longest: 1 year
follow-up
Age Range: 9–18 years Range: 12–17 years Range: 6–12 years
137
Table 19: Evidence summary of multi-component interventions (only

important outcomes reported)
Multisystemic therapy compared with control for adolescents with conduct problems at risk of
offending
Patient or population: Adolescents with conduct problems at risk of offending
Intervention: Multisystemic therapy
Comparison: Control
(studies) evidence (95% CI)
(GRADE)
Number of arrests - short 675 丣丣丣 SMD −0.44

term follow-up (7) moderate1 (−0.82 to −0.06)
(follow-up: 0–4 years)
Arrest 996 丣丣丣 RR 0.64

(follow-up: 0–14 years) (5) moderate1 (0.45 to 0.91)
1 I-squared ⬎50%
Multidimensional treatment foster care compared with control for adolescents with conduct
problems at risk of offending
Patient or population: Adolescents with conduct problems at risk of offending
Intervention: Multidimensional treatment foster care
Comparison: Control
(studies) evidence (95% CI)
(GRADE)
Recidivism 166 丣丣丣丣 SMD −0.55

(follow-up: mean 2 years) (2) high (−0.36, −0.82)
Henggeler and colleagues (2006a) argue the lack of effectiveness reported in

LESCHIED2002 is probably because of problems with treatment fidelity and the
challenges of setting up a new multisystemic therapy service. There were differences
in effectiveness between sites and the site with the lowest fidelity was also found to
have the least favourable outcomes.
There were only two trials that met the inclusion criteria of the review on multi-
dimensional treatment foster care. There was a medium effect favouring multidimen-
sional treatment foster care (SMD ⫽ ⫺0.55; ⫺0.36 to ⫺0.82).
There were three trials assessing other multi-component interventions. It was not
possible to meta-analyse these studies as there were major differences in the interven-
tions and their effectiveness, as well as very high heterogeneity (I2 ⫽ 83.9%). There
was considerable variability in outcomes, with BARRETT2000 finding a large effect
favouring the intervention (SMD ⫽ 1.41; ⫺2.19, ⫺0.63). In contrast, CAVELL2000
138
(SMD ⫽ 0.26; ⫺0.25, 0.77) and FRASER2004 (SMD ⫽ ⫺0.17; ⫺0.60, 0.25) found
no benefit for the intervention.
5.4.21 Clinical evidence summary for multi-component interventions
There is a relatively large evidence base concerning the effectiveness of multisys-

temic therapy. While there was significant heterogeneity, there is good evidence of
efficacy for reducing offending for up to 14 years’ follow-up.
There were promising findings on the efficacy of multidimensional treatment
foster care, with consistent moderate reductions in offending associated with this
intervention compared with treatment as usual.
There is inconclusive evidence for the effectiveness of other multi-component
interventions.
5.4.22 Health economic evidence for multi-component interventions
One study from the US was identified that considered the cost effectiveness of multi-
component interventions targeted at children (Foster et al., 2006). The study evalu-
ated the cost effectiveness of the Fast-Track intervention, a 10-year, multi-component
intervention designed to reduce violence among at-risk children with conduct prob-
lems. The extra costs of the intervention programme versus no treatment were evalu-
ated against three clinical outcomes: cases of conduct disorder averted; criminal
offences avoided; and acts of interpersonal violence averted. Overall, for all three
outcomes, the intervention was not cost effective at conventional willingness-to-pay
thresholds. Subgroup analyses showed that the intervention was more cost effective
for high-risk than low-risk children.
The evidence suggests that for children at risk of going into care, multidimensional
treatment foster care is an effective intervention. For conduct disordered adolescents
for whom parent training is not appropriate and who are at significant risk of offend-
ing, multisystemic therapy is an effective intervention. It is important for both of these
interventions that high fidelity to the model is preserved. The limited economic
evidence from a US setting suggests that multi-component interventions may only be
cost effective in high-risk children.
5.4.24.1 For young people aged between 12 and 17 years with severe conduct prob-
lems and a history of offending and who are at risk of being placed in care
or excluded from the family, consider multisystemic therapy.
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5.4.24.2 Multisystemic therapy should be provided over a period of 3–6 months by

a dedicated professional with a low caseload, and should:
● focus specifically on problem-solving approaches with the family
● involve and use the resources of peer groups, schools and the wider
community.
5.4.24.3 For young people aged between 12 and 17 years with conduct problems at
risk of being placed in long-term out-of-home care, consider multidimen-
sional treatment foster care.
5.4.24.4 Multidimensional treatment foster care should be provided over a period of
6 months by a team of health and social care professionals able to provide
case management, individual therapy and family therapy. This intervention
should include:
● training foster care families in behaviour management and providing a
supportive family environment
● the opportunity for the young person to earn privileges (such as time
on the computer and extra telephone time with friends) when engaging
in positive living and social skills (for example, making their bed and
being polite) and good behaviour at school
● individual problem-solving skills training for the young person
● family therapy for the birth parents to provide a supportive environ-
ment for the young person to return to after treatment.
5.5 COORDINATION OF CARE
The primary objective of early interventions for conduct problems in childhood is to

prevent the development of antisocial personality disorder in adults. However, as will
be clear from the evidence above, these interventions may not always be successful, and
even where a child does not go on to develop ASPD significant mental health problems
may continue into adult life. It is therefore very important that healthcare professionals
working with children effectively coordinate the care they provide and also ensure an
appropriate transition to adult services for those children who require continuing care.
General principles when working with children and their families

5.5.1.1 Child and adolescent mental health service (CAMHS) professionals work-
ing with young people should:
● balance the developing autonomy and capacity of the young person
with the responsibilities of parents and carers
● be familiar with the legal framework that applies to young people,
including the Mental Capacity Act, the Children Acts and the Mental
Health Act.
140
Transition between child and adolescent services to adult services

5.5.1.2 Health and social care services should consider referring vulnerable young
people with a history of conduct disorder or contact with youth offending
schemes, or those who have been receiving interventions for conduct and
related disorders, to appropriate adult services for continuing assessment
and/or treatment.
5.5.2 Research recommendations
Through identifying research limitations from the evidence-based reviews, the

guideline development group has formulated the following research recommenda-
tions.
5.5.2.1 Effectiveness of multisystemic therapy versus functional family therapy

Is multisystemic therapy or functional family therapy more clinically and cost effec-
tive in the treatment of adolescents with conduct disorders? A large-scale RCT
comparing the clinical and cost effectiveness of multisystemic therapy and func-
tional family therapy for adolescents with conduct disorders should be conducted. It
should examine the medium-term outcomes (for example, offending behaviour,
mental state, educational and vocational outcomes and family functioning) over a
period of at least 18 months. The study should also be designed to explore the
moderators and mediators of treatment effect, which could help to determine the
factors associated with benefits or harms of either multisystemic therapy or func-
tional family therapy.
Why this is important

Multisystemic therapy and functional family therapy are two interventions with a
relatively strong evidence base in the treatment of adolescents with conduct disorders,
but there have been no studies directly comparing their clinical and cost effectiveness.
Their use in health and social care services in the UK is increasing. Both interven-
tions target the same population, but although they share some common elements
(that is, work with the family), multisystemic therapy is focused on both the family
and the wider resources of the school, community and criminal justice systems, and
through intensive individual case work seeks to change the pattern of antisocial
behaviour. In contrast, functional family therapy focuses more on the immediate
family environment and uses the resources of the family to change the pattern of anti-
social behaviour. The study should be designed to facilitate the identification of
subgroups within the conduct disorder population who may benefit from either multi-
systemic therapy or functional family therapy.
5.5.2.2 Interventions for infants at high risk of developing conduct disorders

Do specially designed parent-training programmes focused on sensitivity enhance-
ment (a set of techniques designed to improve secure attachment behaviour between
141
parents and children) reduce the risk of behavioural disorders, including conduct
problems and delinquency, in infants at high risk of developing these problems? An
RCT comparing parent-training programmes focused on sensitivity enhancement
with usual care should be undertaken. It should examine the long-term outcomes
over a period of at least 5 years, but with consideration given to the possibility of a
further 10-year follow-up. The study should also be designed to explore the moder-
ators and mediators of treatment effect that could help determine the factors associ-
ated with benefits or harms of the intervention.

There is limited evidence from non-UK studies that interventions focused on devel-
oping better parent–child attachment can have benefits for infants at risk of develop-
ing conduct disorder. Determining the criteria and then identifying children at high
risk (usually via parental risk factors) is difficult and challenging. Even when these
factors are agreed, engaging parents in treatment can be difficult. It is important that
a range of effective interventions is developed to increase the treatment choice and
opportunities for high-risk groups. Several interventions, such as Nurse–Family
Practitioners, are being developed and trialled in the UK. It is important for this group
of children to have an alternative, effective intervention.
142
Risk assessment and management
6 RISK ASSESSMENT AND MANAGEMENT
6.1 INTRODUCTION
At the population level there is a strong statistical association between the diagnosis
of antisocial personality disorder and offending (including violent offending). The
Office for National Statistics’ study found antisocial personality disorder in 63% of
male remand prisoners, 49% of male sentenced prisoners and 31% of female prison-
ers in England and Wales (Singleton et al., 1998). In the National Confidential
Inquiry’s study of the 249 homicide offenders who had recent contact with psychi-
atric services (Appleby et al., 2006), 30% had a primary or secondary diagnosis of
personality disorder, and the inquiry concluded that this figure was almost certainly
an underestimate. There are similar statistics from health and criminal justice settings
and from community samples.
With the growth of offending behaviour programmes in the criminal justice
system and the expansion of personality disorder services in the NHS, both criminal
justice and healthcare systems are devoting considerable resources to discovering the
extent to which mental health treatments can reduce the offending risk associated
with antisocial personality disorder. However as will be apparent throughout this
chapter, it should be cautioned that there is more research on risk assessment than on
risk management. Until such evidence emerges it is necessary to keep expectations of
health service interventions around risk within reasonable bounds.
6.2 ASSESSMENT OF VIOLENCE RISK
6.2.1 Introduction
The diagnosis of antisocial personality disorder, like some other mental disorders, is
associated with an increased risk of offending behaviour, including violence.
However, antisocial personality disorder is a very broad diagnostic category (see
DSM-IV; APA, 1994), even when compared with other diagnoses in mental health. It
encompasses people who never commit offences as well as a minority who commit
the most serious crimes, with a great range in between. As a result the diagnosis alone
is of little value as an indicator of violence risk.
The clinical assessment of violence risk in antisocial personality disorder is more
problematic than in some other mental disorders, such as schizophrenia, because anti-
social personality disorder lacks unequivocal symptoms such as delusions and hallu-
cinations. The clinical interview and mental state examination are therefore less
reliable as a means of assessing the severity of the disorder. Some patients may be
143
both persuasive and deceptive, making a clinical interview a poor guide to the sever-
ity of the disorder and its associated risks. Therefore much effort has been expended
on the development and evaluation of tools that may assist in the assessment of
violence risk. Any measure that discriminates between degrees of severity of antisocial
personality disorder is likely to be of assistance in risk assessment; the Psychopathy
Checklist (Hare, 1980; Hart, 1998a, 1998b) is therefore one of the most useful instru-
ments in this field.
The statistical evaluation of risk assessment tools

Risk assessment is concerned with probability, therefore it lends itself to a statistical
approach comparing prediction and outcome. In order to evaluate risk assessment
tools it is necessary to appraise the extent to which they maximise the detection of
violent outcomes (true positives) while minimising the number of false alarms (false
positives). Table 20 sets out the model for the possible outcomes of violence risk
prediction.
Table 20: Possible outcomes of violence risk prediction
Violent outcome Non-violent outcome

Predicted violence True positive (TP) False positive (FP)
Predicted non-violence False negative (FN) True negative (TN)
In this model the quality of the test or tool is judged by two main criteria:
Sensitivity is defined as the proportion of the violent outcome group scoring positive
for predicted violence on the risk assessment instrument, that is, sensitivity ⫽
TP/(TP ⫹ FN).
Specificity is defined as the proportion of the non-violent outcome group scoring in

the predicted non-violence group on the risk assessment instrument, that is, speci-
ficity ⫽ TN/(FP ⫹ TN).
There is a trade-off between these measures. As the test or tool is made less strin-
gent by lowering the cut-off score it picks up more true positives (sensitivity rises) but
it also picks up more false positives (specificity falls). The ideal is to maximise sensi-
tivity while keeping specificity high.
To illustrate this: from a population in which the point prevalence rate of depres-
sion is 10% (that is, 10% of the population has depression at any one time), 1000
women are given a test with 90% sensitivity and 85% specificity. It is known that 100
women in this population have depression, but the test detects only 90 (true positives),
leaving 10 undetected (false negatives). It is also known that 900 women do not have
depression, and the test correctly identifies 765 of these (true negatives), but classi-
fies 135 incorrectly as having depression (false positives). The positive predictive
144
value of the test (the number correctly identified as having depression as a proportion
of positive tests) is 40% (90/90 + 135), and the negative predictive value (the number
correctly identified as not having depression as a proportion of negative tests) is 98%
(765/765 + 10). Therefore, in this example, a positive test result is correct in only
40% of cases, while a negative result can be relied upon in 98% of cases.
The qualities of a particular tool are summarised in a receiver operator character-
istic (ROC) curve, which plots sensitivity (expressed as %) against (100% - specificity)
(see Figure 3).
A test with perfect discrimination would have a ROC curve that passed through
the top left hand corner; that is, it would have 100% specificity and pick up all true
positives with no false positives. In reality that is never achieved, but the area under
the curve (AUC) measures how close the tool achieves the ideal. A perfect test would
have an AUC of 1 and anything above 0.5 is better than chance.
The AUC is the preferred statistic for evaluating risk assessment tools and is the
most common metric used in such studies (Mossman, 1994). Its main advantage, in
comparison with the other statistics, is that such estimates appear not to be affected
by the base rate of the phenomenon under consideration, which in this case is
violence (see Mossman, 1994). For these reasons, the review below uses AUC to
compare tools used for violence risk assessment.
Figure 3: An example ROC curve
Statistical prediction and healthcare

While the AUC is used because it is generally agreed to be the best available statistic
(Mossman, 1994), practitioners should be wary of the uncritical application of statis-
tical approaches to risk assessment and management in a health setting. The main
problems are set out below.
145
Statistics take no account of the values that are central to healthcare: The AUC
statistic is concerned with maximising the number of right decisions. As violence
is relatively unusual in mental health populations, Monahan (1981) pointed out that
the best way to be right most of the time is to predict that no patients will be violent.
That course of action is unacceptable because errors in medicine come with values
attached and their values are not equal. The consequences of failing to predict an
act of serious violence (a false negative) are very different from the consequences
of wrongly predicting violence (a false positive). Fulford and colleagues (2006)
have written extensively on the importance of values in mental health; for the
purposes of this discussion the crucial point is that the statistics cannot be considered
in isolation.
The apparent value of a risk prediction instrument will be determined to a large
extent by the population to which it is applied: Gordon (1977) observed that many
risk assessments are tested in prisoner populations where there are high baseline
levels of violence risk. The same is true of many of the studies summarised below.
In these circumstances it is perhaps remarkable that these instruments are able to
achieve a reasonable level of discrimination. Clinicians who work with a more aver-
age group of patients may therefore reasonably expect that a standardised assess-
ment may be even more effective in identifying patients who have a high violence
risk. This principle leads to a paradox. Standardised risk assessments are most
widely used in forensic populations where most patients will have an increased
violence risk, meaning that fine discrimination between degrees of risk is more diffi-
cult. In a general psychiatry population, where most patients have a lower level of
risk, standardised instruments ought to be of more value in identifying the small
number who present a high risk.
Even the best instruments have high rates of error when applied to individuals:
Sensitivity, specificity and the AUC are population or group measures, but there are
much greater uncertainties associated with individual prediction. In part this limita-
tion is intrinsic to the statistical method; just because an individual has most attrib-
utes of a group does not mean he or she has all of them, even though those attributes
generally go together.
Violence risk prediction is different because the reality is ambiguous and it is
also subject to change. All the evidence concerning a particular individual may indi-
cate an extremely high risk of violence but it counts for nothing if the potential
perpetrator meets with an accident or dies of natural causes on his or her way to
committing an act of violence. More realistically, a medical intervention or supervi-
sion on probation can turn a true positive into a false positive, by preventing an act
of violence.
Violence risk is multifaceted rather than unitary: A comprehensive assessment of
violence risk includes qualitative and descriptive elements. For example, it may spec-
ify the likely victim or class of victim (for example, women and children), the type of
violence (for example, sexual versus non-sexual, predatory versus impulsive), the
severity (for example, use of weapons, whether the violent act is life-threatening, and
so on) and the frequency and probability of violence. Statements of probability will
146
usually be conditional on, for example, availability of alcohol and involvement in

destabilising relationships. Different considerations apply to the management of, for
example, low frequency but life-threatening predatory violence on the one hand and
frequent, impulsive, and less serious violence on the other. It is impossible to encapsu-
late this complexity within a unitary statistical measure. In clinical practice a good risk
assessment is not a statement of probability but a comprehensive description of many
different aspects.
6.2.2 Current practice
It is generally accepted that the best way of assessing violence risk in mental health
settings is through structured clinical judgement (Monahan et al., 2001). The alterna-
tive methods are unstructured clinical judgement and actuarial measures. Unstructured
clinical judgement relies on the skills of the individual clinician and has no rules
beyond the basic rules of clinical practice. The clinician is free to take into account
any information they see fit, and they can use their discretion to arrive at a judgement
of violence risk.
The unstructured clinical approach is widely used but it is becoming difficult to
defend. Although it can work reasonably well it depends on individual skill, experi-
ence and thoroughness. Practice varies between individuals and, because there is no
structure or standard, it is virtually impossible to give explicit training or to raise stan-
dards. Decisions lack transparency so it is difficult to guard against bias and to guar-
antee non-discriminatory practice. Communication is compromised because there is
no common language or agreed set of variables.
In a reaction against the clinical method, the actuarial approach specifies the infor-
mation to be collected and how it is to be analysed in order to arrive at a decision. The
exercise of clinical discretion is explicitly forbidden in order to exclude bias. This
approach is derived from the insurance industry and it is surprisingly effective in
predicting violence at the population level.
However, actuarial methods are less useful or appropriate in a clinical setting
because the focus is on the individual patient. When applied to individuals, actuarial
or standardised measures will often be inaccurate because they ignore idiosyncratic
features, including both protective and aggravating factors. For example, morbid jeal-
ousy may be associated with a very high risk of violence even in the absence of other
actuarial risk factors. Conversely, the onset of incapacitating physical illness may
lower violence risk even when all the actuarial indicators are present.
In principle there is also an objection to relying on actuarial measures in clinical
settings. They treat the individual as nothing more than a representative of a class of
people, all of whose characteristics are assumed to be identical. It could be argued that
such measures rely on the same logic as prejudice and are therefore incompatible with
the value placed by health services on individual formulation and needs assessment.
Despite these reservations, actuarial assessments such as the Violence Risk
Assessment Guide (VRAG; Quinsey et al., 1998), the Sex Offender Risk Assessment
147
Guide (Quinsey et al., 1998), and Static-99 (Hanson & Thornton, 1999) are widely
used by forensic mental health services. They should not be used as stand-alone
measures of risk but will often form part of a comprehensive assessment. When
used in that way they become incorporated into the exercise of structured clinical
judgement.
Structured clinical judgement combines the positive aspects of the actuarial and
clinical approaches. There is a mandatory requirement to collect standardised infor-
mation, but the clinician is free to interpret that information in the light of all that is
known about the individual case. There is some standardisation and transparency
while clinicians retain the freedom to take into account any and all available informa-
tion before reaching a decision.
The most widely used instrument in the field of structured clinical judgement is
the Historical, Clinical, Risk Management-20 (HCR-20; Webster et al., 1997) which
involves the collection of 20 items (see Section 6.2.5). It then requires consideration
of any items that may be specific to the particular case, before requiring clinical teams
to construct risk management scenarios. Each scenario considers a possible violent
outcome, along with warning signs and factors that make it more or less likely, lead-
ing to a plan for managing those risk factors.
Despite the importance given to clinical discretion, this method is based on stan-
dardised measures of risk. It requires that clinical decisions are informed by such
measures rather than determined by them but it still raises questions about the accu-
racy of the tools used for violence risk prediction. The next section considers the
extent to which such measures are successful in predicting violence risk in popula-
tions of people with antisocial personality disorder.
6.2.3 Definition and aim of topic of review
Risk assessment tools are defined in the review as validated psychometric instruments
that are used to predict violence and/or offending. The review was limited to assess-
ment tools that in the view of the GDG were likely to be used in UK clinical practice.
They included the Psychopathy Checklist in its full (PCL-R; Hare et al., 1991) and
screening versions (PCL-SV; Hart et al., 1999), HCR-20 (Webster et al., 1997),
VRAG (Quinsey et al., 1998), Level of Supervision Inventory (LSI; Andrews &
Bonta, 1995), Offender Group Reconviction Scale (OGRS; Copas & Marshall, 1998),
and Risk Assessment Management and Audit Systems (RAMAS; O’Rourke &
Hammond, 2000).
GRADE profiles could not be generated because the guidance and software on
grading reviews of such studies are at a preliminary stage. Therefore quality assess-
ments for each individual study were provided in the evidence summary tables. The
following review assesses predictive validity. It does not replicate the clinical use of
these tools nor does it imply they should be used for risk assessment in a clinical
setting. In some cases the tools were not designed or intended for risk prediction but
that should not be an obstacle to their statistical evaluation.
148
The review team conducted a new systematic search for observational studies that
assessed the risk of antisocial behaviour, focusing on violence and/or offending (see
Appendix 8).
Broad inclusion criteria were adopted because there was initial interest in the
capacity of the scale to predict violence/offending behaviour not exclusive to antiso-
cial personality disorder. The interventions consisted of risk assessment tools seeking
to predict violent and/or offending behaviour at either the group or individual level
using outcomes such as sensitivity, specificity, the AUC, PPV and NPV. The primary
outcome measure examined was AUC with values of 0.6 to 0.8 indicating a moderate
level of prediction, 0.8 to 0.9 a high level of prediction and values greater than 0.9
indicating a very high level of prediction.
Trials consisting of 30% or more of participants with schizophrenia or psychoses
were excluded from the analysis.
Twenty studies met the inclusion criteria set by the GDG. Of these, 19 were
published in peer-reviewed journals between 1991 and 2007. One further study was
a publication from the Ministry of Justice (Coid et al., 2007). In addition, 38 studies
were excluded from the analysis. The most common reason for exclusion was not
providing relevant data that met the criteria of the review.
Table 21: Databases searched and inclusion/exclusion criteria for clinical

effectiveness of psychological interventions

Date searched Database inception to November 2007; table of
contents November 2007 to June 2008
Study design Observational studies
Patient population People with antisocial personality disorder; people in
psychiatric institutions; people in prison
Interventions Risk assessment tools
Outcomes Sensitivity, specificity, the AUC, positive predictive
validity (PPV), negative predictive validity (NPV)
149
Of the 19 included studies, five assessed the HCR-20, 15 the Psychopathy PCL-R,
three the PCL-SV, eight the VRAG, three the LSI and one the OGRS. No studies on
RAMAS met the eligibility criteria of the review.
Historical, Clinical, Risk Management-20 (HCR-20)

The HCR-20 (Webster et al., 1997) takes a structured clinical assessment approach to
risk assessment. This scale consists of 20 items on historical, clinical and risk
management issues. The ten historical items include previous violence, substance
misuse problems, major mental illness, psychopathy and personality disorder. The
five clinical items are concerned with lack of insight, negative attitudes, active symp-
toms of mental illness, impulsivity and unresponsiveness to treatment. The five risk
management items include feasibility of plans, exposure to destabilisers (destabilis-
ing influences that may be general or specific to the individual), lack of personal
support, non-compliance with remediation attempts and stress.
The HCR-20 is an aid to clinical management of violence risk in individuals.
Some aspects of it, namely the formulation of risk scenarios, make sense only in an
individual clinical context and are not amenable to statistical evaluation as predictors
of risk. Nevertheless the HCR-20 has at its core 20 items said to correlate strongly
with violence risk. It is both valid and essential to examine the predictive value of
those items, while recognising that it is an artificial exercise not intended to represent
clinical use of the tool. The HCR-20 requires the 20 items to be used as the basis for
a formulation and risk management plan which goes beyond simple, actuarial predic-
tion. Even so, if the 20 items had no predictive value it would be impossible to justify
their inclusion in preference to any other collection of items.
Five studies were identified that met the eligibility criteria of the review. A summary
of the study information and data for each of these studies is provided in Table 22.
Most studies reported data on the area under the curve (AUC). Only Grann and
colleagues (2000) provided additional information on sensitivity and specificity.
Mean follow-up period ranged from 2 to 10 years.
AUC statistics ranged from 0.6 to 0.8 in most studies indicating that the HCR-20 was
moderately predictive of violence and/or offending. A pooled estimate was obtained
from studies (Dahle, 2006; Grann et al., 2000; Warren et al., 2005; Morrissey et al.,
2007) providing extractable data (AUC ⫽ 0.68; 0.65, 0.71). Almost all studies individu-
ally found AUC values to be statistically significant; only Warren and colleagues (2005)
reported consistent evidence of no effect. This may be explained by the sample consist-
ing only of women; most other studies included samples that were either exclusively or
predominantly male. Serious violence is relatively unusual in women and may be asso-
ciated with different causal factors than those that operate in men.
Clinical use of the HCR-20 allows for the inclusion of idiosyncratic risk items that
may increase its predictive power. This flexibility means the HCR-20 can include
clinical consideration of risks arising from (for example) sexual offending, stalking,
morbid jealousy or dysfunctional intimate relationships even though it does not lend
itself to statistical evaluation in these areas. In short it is argued by its proponents that
the HCR-20 (and other structured clinical systems of risk management) has greater
clinical utility than is reflected in a statistical analysis of group prediction. While the
150
Table 22: Study information and data on the HCR-20
Study Population/setting Follow-up Outcome Result Quality

Coid et al., N = 1396 6 days – 2.91 Serious Any: AUC = 0.630 +
2007 (1353 prisoners years re-offending (p < 0.001)
released) (M = 1.97
years) Drug: AUC = 0.577
Gender: all male (p < 0.01)
Setting: prisoner cohort, Theft: AUC = 0.667

UK (p < 0.001)
Robbery:
AUC = 0.565 (ns)
Violence:
AUCs = 0.638
(p < 0.001)
Dahle, 2006 N = 307 10 years Criminal Reimprisonment ++
convictions 5 years post-release:
Mean age at baseline: AUC = 0.70,
30 years (SD = 5.35) SD = 0.03
Moderately
Gender: all male predictive
Setting: German Reimprisonment

prisons 10 years post-
release: AUC = 0.71,
SD = 0.03
Grann et al., Personality disorder: 2 years Violent Personality disorder +

2000 (only N = 358 (also post-release crime only: AUC = 0.71
10 history schizophrenia: N = 202) (retrospect- (0.66, 0.76)
items used – tive)
with some Age: 32 years Cut-off 12:
modifica- sensitivity = 0.72,
tion) Gender: 322 men, specificity = 0.60,
36 women PPV = 0.38,
NPV = 0.86
Setting: retrospective
follow-up of violent
offenders receiving
forensic psychiatric
evaluation, Sweden
Morrissey N = 73 (60 patients 12 months Institutional Interpersonal physi- +

et al., 2007 remained in institution aggression cal aggression:
at 12-month follow-up) AUC = 0.68
(0.56-0.81; p < 0.05)
Gender: all male
Continued
151

Age: 43–76 Verbal and property
(M = 38; SD = 8.9) aggression:
AUC = 0.77
Setting: high security (0.64–0.88;
forensic intellectual p < 0.01)
disability service,
England and Wales
Learning disability
Diagnosis: 81% mental

retardation, 54.8%
personality disorder,
28.8% psychotic
disorder, 8% mood
disorder (including dual
diagnosis)
Warren N = 132 (completers – 12 months Criminal High correlation +

et al., 2005 261 at baseline) convictions with PCL-R
(r =.80, p < .01)
Gender: all female
Did not predict
Age: 60.3% under 32 violent crime:
39.67% over 32 Violent crime –

AUC = 0.49
Setting: maximum (0.38, 0.59)
security prisons, US
Potentially violent
crime – AUC = 0.60
(0.49, 0.72)
Crimes against
persons –
AUC = 0.46
(0.36, 0.56)
But predicted non-

violent crime:
AUC = 0.68
(0.56, 0.80)
methodological challenges are considerable it seemed to the GDG that such a claim
could be tested empirically. No evidence is available at present.
Psychopathy Checklist
Psychopathy is more or less synonymous with the categories of antisocial personality
disorder in DSM-IV and with dissocial personality in ICD-10 (Maden, 2007). The
152
Psychopathy Checklist Revised (PCL-R; Hare, 1991) is a measure of psychopathy

rather than risk but it has been shown to correlate highly with violence risk in many
situations and it is widely used in violence risk assessment as a measure of severity for
antisocial personality disorder. In fact the PCL-R is one of the most widely researched
of all violence risk assessment tools. This scale consists of 20 items providing a score
from 0 to 40. A more recent screening version (PCL-SV) has also been developed
based on only 12 items providing a score from 0 to 24 (Hart et al., 1999). Although the
PCL-SV is less widely researched than the PCL-R it too has an established correlation
with violence risk. In the MacArthur study of violence in general psychiatric patients
the PCL-SV was the single best predictor of subsequent violence (Monahan et al.,
2001). Both versions can be scored based on case notes alone, with an optional inter-
view for additional information. Psychopathy is generally defined as a score of 30 or
above in North America and 25 or above in Europe (Maden, 2007).
Fifteen studies were identified that met the eligibility criteria of the review. A
summary of the study information and data for each of these studies is provided in
Table 23. Most studies were of the PCL-R, but three (Edens et al., 2004; Urbaniok,
2007; Walters et al., 2007) were of the PCL-SV.
Follow-up ranged from 2 to 32 years. As with the HCR-20, most studies reported
an AUC ranging from 0.60–0.80 suggesting the PCL-R and PCL-SV versions are
moderately predictive of violence and/or offending. Only three studies (Morrissey
et al., 2007; Walters & Mandell, 2007; Warren et al., 2005) reported non-significant
Table 23: Study information and data on the PCL-R and PCL-SV
Buffington- N = 58 2 years Institutional Cut-off 30 – Any: +

Vollum et al., disciplinary sensitivity = 0.36,
2002 (PCL-R) Gender: all male offences specificity = .88,
PPV = 0.69,
Age: 35.22 (SD = 10.72) NPV = 0.64
Sex offenders Cut-off 30 – Physically

aggressive:
Setting: prison, US sensitivity = 0.40,
specificity = 0.79,
PPV = 0.14,
NPV = 0.93
Cut-off 30 – Verbally
aggressive:
sensitivity = 0.38,
specificity = 0.88,
PPV = 0.69,
NPV = 0.67
Cut-off 30 – Non-
aggressive:
sensitivity = 0.35,
specificity = 0.83,
PPV = 0.46,
NPV = 0.76
Continued
153
Coid et al., N = 1396 (1353 prisoners 6 days – 2.91 Serious Any: AUC = 0.646 ++
2007 (PCL-R) released) years (M = 1.97 re-offending (p < 0.001)
years)
Gender: all male Drug: AUC = 0.596
(p < 0.001)
Setting: prisoner cohort,
UK Theft: AUC = 0.662
(p < 0.001)
Robbery: AUC = 0.570

(ns)
Violence: AUC = 0.639

(p < 0.001)
Dahle, 2006 N = 307 10 years Criminal Reimprisonment 5 ++

(PCL-R) convictions years post-release:
Mean age at baseline:
30 years (SD = 5.35) AUC = 0.69, SD = 0.03
Gender: all male
Setting: German prisons
Edens et al., N = 695 (441 not 50 weeks Violence At least one violent +
2006 (PCL- followed up) act:
SV)
(McArthur Age: 30 years 20-week follow-up:
study) AUC ⫽ 0.78
Gender: 59% male 50-week follow-up:
Setting: hospitals in US AUC = 0.76
Diagnosis: 40% depression

or dysthymia, 24%
substance misuse
disorders, 17% schizophre-
nia or schizo-affective
disorder, 13% bipolar
disorder, 4% other disorder,
2% personality disorder
Grann et al., N= 352 8 years Violent Violent recidivism: +

1999 (PCL-R) Age: 32 (range 16–72) (retrospective) recidivism
Gender: 316 men, 36 2 years – AUC = 0.72
women (0.66–0.78)
Setting: Court ordered
forensic psychiatric 5 years – AUC = 0.70
evaluations, Sweden (0.63–0.76)
Diagnosis: 100%
Harris et al., N = 176 (169 had the 10 years Violent Relative improvement
1991 (PCL-R) opportunity to recidivate) recidivism over chance +
(RIOC) = 62.4%
Gender: all male (p < .001)
Continued
154
Age: under 25
Setting: maximum security

psychiatric hospital
Kroner & N = 78 2 years Violent and Violent recidivism: +

Loza, 2001 non-violent AUC = 0.70
(PCL-R) Mean age at baseline: recidivism
29 years (SD = 8.3) Non-violent recidi-
vism: AUC = 0.70
Gender: all male
Setting: prisons, Canada
Kroner et al., N = 206 – Post-release New convictions: +

2005 (PCL-R) criminal AUC = 0.67
Age: 30 years convictions
Revocations:
Gender: all male Revocations AUC = 0.67
(violations
Setting: violent offenders, of parole
Canada leading to
reincarcera-
tion)
Loza & N =91 5 years Violent and Violent recidivism: +

Green, 2003 general AUC = 0.67
(PCL-R) Mean age: 30 recidivism
General recidivism:
Gender: all male AUC = 0.67
Setting: released from

prison, Canada
Morrissey N = 73 (60 patients 12 months Institutional Interpersonal physical +

et al., 2007 remained in institution at aggression aggression:
(PCL-R) 12-month follow-up). AUC = 0.54
(0.39–0.68)
Gender: all male
Verbal and property
Age: 43–76 (M = 38; aggression:
SD = 8.9) AUC = 0.49
(0.32–0.65)
Setting: high security
forensic intellectual
disability service,
England and Wales
Learning disability
Diagnosis: 81% mental

retardation, 54.8%
personality disorder, 28.8%
psychotic disorder, 8%
mood disorder (including
dual diagnosis)
Continued
155
Salekin et al., N = 78 12–16 months Recidivism Cut-off 29: +

1998 (PCL-R) sensitivity = 0.11,
Gender: all female specificity = 0.91,
PPV = 0.50,
Age: 30.57 (SD = 7.69) NPV = 0.55
Setting: prison in US AUC = 0.64
Urbaniok N = 96 18–32 years Recidivism Cut-off 18 – combined

et al., 2007 (combined = recidivism: AUC =
(PCL-SV) Age: 18–77 (M = 29.7, violent and 0.59 (0.49–0.68)
SD = 9.3) sexual)
Cut-off 15 – combined
Gender: all make recidivism: AUC =
0.61 (0.50–0.71)
Setting: Switzerland
Diagnosis: 70.8% personal- recidivism: AUC = +
ity disorder 0.69 (0.59–0.89)
recidivism: AUC =
0.64 (0.55–0.73)
Cut-off 18 – violent
recidivism: AUC =
0.56 (0.47–0.68)
Cut-off 18 – sexual
recidivism: AUC = 0.57
(0.42–0.71)
Walters et al., N = 185 2 years Institutional Any disciplinary +

2003 (PCL-R) disciplinary offence – AUCs = .575
offences
Age: 36.55 (SD = 9.61)
Setting: prison US
Diagnosis: 45.4%
personality disorders,
20.0% no disorder, 9.2%
substance use disorders,
7.0% schizophrenic disor-
ders, 5.9% other psychoses,
4.3% mood disorders,4.3%
sexual disorders, 2.7%
anxiety disorders, 1.1%
adjustment disorders
Institutional Any incident – AUC =
Walters & N = 136 2 years incidents 0.522 (0.42–0.62)
Mandell,
2007 Age: 20–65 years Major incident –
(PCL-SV) (M = 34.24, SD = 8.50) AUC = 0.60
(0.49–0.71)
Gender: all males
Continued
156
Setting: medium secure Aggressive incident –

prison US AUC = 0.62
(0.48–0.77)
Warren et al., N = 132 (completers – 261 12 months Criminal Prediction of crime: +

2005 (PCL-R) at baseline) convictions did not predict violent
crime
Gender: all female
Violent crime –
Age: 60.3% under 32 AUC = 0.46
(0.36–0.56)
39.67% over 32
Potentially violent
Setting: maximum security crime – AUC = 0.62
prisons, US (0.52–0.73)
Crimes against persons

– AUC = 0.50
(0.40–0.60)
But predicted non-

violent crime:
AUC = 0.67
(0.56–0.79)
AUC statistics. Pooled estimates of AUC values for the PCL-R (Dahle, 2006; Grann
et al., 1999; Warren et al., 2005) and PCL-SV (Urbaniok et al., 2002; Walters &
Mandell, 2007) were calculated from studies that provided extractable data. It appears
that the PCL-R (AUC ⫽ 0.69; 0.67, 0.70) predicted violence or offending slightly
better than PCL-SV (AUC ⫽ 0.58; 0.54, 0.63).
The non-significant findings may partly be explained by the populations in these
studies. As discussed above, Warren and colleagues (2005) comprised an exclusively
female population within a high secure prison in the US. Similarly, Morrissey and
colleagues (2007) differed from other studies in focusing on a sample of people with
intellectual disability. Finally, Walters and colleagues (2003) focused on disciplinary
violations whereas most other studies reported recidivism rates.
Violence Risk Assessment Guide (VRAG)

The VRAG (Quinsey et al., 1998) takes an actuarial approach to risk assessment. The
12 items were derived from a study of 600 male patients released from a high secure
hospital in Canada as the highest predictors of violence at 7 years’ follow-up. These
items include PCL-R score, problems at junior school, alcohol misuse, age, personal-
ity disorder and so on. The main criticism of VRAG is its lack of face validity, that is,
three items scored by VRAG as being associated with reduced risk (having a
diagnosis of schizophrenia, extent of victim injury and female victim) appear to
contradict clinical judgement and the wider literature (Maden, 2007).
Eight studies were identified that met the eligibility criteria of the review. A summary
of the study information and data for each of these studies is provided in Table 24.
157
Table 24: Study information and data on the VRAG
Coid et al., N = 1396 (1353 prisoners 6 days – 2.91 Serious Any: AUC = 0.719 +
2007 released) years (M = 1.97 re-offending (p < 0.001)
years)
Gender: all male Drug: AUC = 0.655
(p < 0.001)
Setting: prisoner cohort,
UK Theft: AUC = 0.713
(p < 0.001)
Robbery: AUC = 0.623

(p < 0.001)
Violence: AUC = 0.700

(p < 0.001)
Edens et al., N = 695 (441 not 50 weeks Violence At least one violent +
2006 followed up) act:
(McArthur 20-week follow-up:
study) Age: 30 years Modified VRAG –
AUC = 0.73
Gender: 59% male Modified VRAG
without PCL-SV –
Setting: hospitals in US AUC = 0.64
Diagnosis: not reported 50-week follow-up:

Modified VRAG
without PCL-SV –
AUC = 0.64
Grann et al., Personality disorder: 2 years Violent Personality disorder +

2000 (only 10 N = 358 (also schizo- post-release crime only: AUC = 0.68
history items phrenia: N = 202) (retrospective) (0.62–0.73)
used – with
some modifi- Age: 32 years Cut-off 13:
cation) sensitivity = 0.57,
Gender: 322 men, specificity = 0.71,
36 women PPV = 0.40,
NPV = 0.83
Setting: retrospective
follow-up of violent
offenders receiving
forensic psychiatric
evaluation, Sweden
Harris et al., N = 396 Retrospective Violent Violent recidivism +

2003 (sub- analysis – recidivism AUC = 0.73
sample of Age: 36 years (SD = 11) 3 years (0.68–0.78)
Quinsey1998) Sexual
Gender: all male recidivision Sexual recidivism:
AUC = 0.65
Setting: sex offenders (0.59–0.71)
(child molesters and/or
rapists) in prison or at risk
of re-offending, Canada
Diagnosis: 63% personality

disorder, 4% schizophrenia
Continued
158
Kroner & N = 78 2 years Violent and Violent recidivism: +

Loza, 2001 non-violent AUC = 0.64
Mean age at baseline: recidivism
29 years (SD = 8.3) Non-violent
recidivism:
Setting: prisons, Canada

2005 criminal AUC = 0.75
Revocations:
Gender: all male Revocations AUC = 0.73
(violations
Setting: prison, Canada of parole
leading to
reincarcera-
tion)
Loza & N = 91 5 years Violent and Violent recidivism: +

Green, 2003 general AUC = 0.63
Mean age: 30 recidivism
General recidivism:
Setting: released from

prison, Canada
Rice & N = 288 (N = 159 were 10 years Recidivism Violent recidivism: +

Harris, 1997 not included in the AUCs = 0.76 (N = 288)
development of VRAG)
Gender: all male Sexual recidivism:
Sex offenders AUCs = 0.77 (N = 159
sex offenders)
AUC values once more ranged from 0.60-0.80 indicating a moderately accurate
prediction for the risk of violence and/or offending. A pooled estimate was obtained
from studies (Grann et al., 2000; Harris et al., 2003) providing extractable data
(AUC ⫽ 0.65; 0.55, 0.77).
Offender Group Reconviction Scale (OGRS)

OGRS (Copas & Marshall, 1988) is another actuarial instrument that focuses on the
prediction of offending at the group level for offenders in England and Wales. It has
five static factors: age, sex, number of previous convictions, number of custodial
sentences under 21 years of age, and seriousness of the index offence.
One study was identified that met the eligibility criteria of the review. A summary
of the study information and data for the included study is provided in Table 25. Three
studies were excluded because they consisted of samples with greater than 30% of
participants having a diagnosis of schizophrenia.
159
Table 25: Study information and data on the OGRS
Study Population/ Follow-up Outcome Result Quality

setting
Coid et al., N = 1396 6 days – 2.91 Serious Any: AUC = +
2007 (1353 prisoners years (M = 1.97 re-offending 0.77 p < .001
released) years)
Drug: AUC ⫽
Gender: all male 0.69 p < .001
Setting: prisoner Theft: AUC ⫽

cohort, UK 0.76 p < .001
Robbery:
AUC = 0.69
p < .001
Violence:
AUC = 0.72
p < .001
The AUC ranged from 0.69 to 0.72 indicating a moderately accurate prediction.
However, the data were too sparse to be able to draw conclusions on the efficacy of
this assessment tool for the target population of this review.
Level of Service Inventory (LSI)

The LSI (Andrews & Bonta, 1995) is another actuarial instrument designed to predict
re-offending and the need for probation supervision. The LSI consists of 54 items and
10 subscales using both static (for example, age and previous conviction) and
dynamic factors (for example, alcohol misuse and accommodation problems) to
predict re-offending.
Three studies were identified that met the eligibility criteria of the review; all were
focused on predicting criminal convictions either generally or more specifically of
violent recidivism. A summary of the study information and data for each of these
studies is provided in Table 26.
As with the previous instruments the AUC values ranged from 0.60 to 0.80; all
were statistically significant and indicated moderate predictive validity. However, it
was not possible to pool the AUC values because of a lack of extractable data—only
Dahle (2006) provided sufficient detail.
6.2.6 Clinical evidence summary
There was considerable similarity in the AUC values obtained for most of the scales
reviewed. The PCL-R, LSI, OGRS and HCR-20 all had AUC values indicating a
moderate level of prediction. Therefore there are a number of measures available that
160
Table 26: Study information and data for LSI
Study Population/ Follow-up Outcome Result Quality

setting
Dahle, 2006 N = 307 10 years Criminal Re-imprisonment ++
convictions 5 years post-release:
Mean age at AUC = 0.70, SD = 0.03
baseline: 30 years
(SD = 5.35) Reimprisonment
10 years post-release:
Gender: all male AUC = 0.65, SD ⫽ 0.03
Setting: German
prisons
2005 criminal AUC = 0.69
Revocations Revocations:
Gender: all male (violations of AUC = 0.71
parole leading to
Setting: prison, reincarcer-ation)
Canada
Loza & Green, N = 91 5 years Violent and Violent recidivism: +
2003 general AUC = 0.67
Mean age: 30 recidivism
General recidivism:
Setting: released
from prison, Canada
are adequately effective at predicting violence and/or offending at the group level,
with little data to differentiate them.
While these studies provide useful data on the prediction of recidivism and
violence at the group level, there are limits to applying this data in clinical practice.
Risk assessment instruments measure the extent to which an individual resembles a
group in which there is a particular, statistical risk of violence. The instrument may
tell professionals more about that individual than they would know if they did not
carry out the assessment, but it has limited accuracy as a predictor of the individual’s
behaviour.
All of the risk assessment tools included in the review appeared to predict risk moder-
ately well and there did not appear to be clear evidence to distinguish these measures
161
in their level of prediction. Therefore the GDG concluded that the use of a structured
instrument would be beneficial as a supplement to a structured clinical assessment. It
was also noted that these measures should be provided by staff with sufficient expert-
ise (for example, working in tertiary services) and already be familiar in UK clinical
practice (for example, the PCL-R, PCL-SV and HCR-20).
In addition, for secondary services, where there may not be the resources to
conduct assessments using such instruments, the GDG felt it would be important for
staff to record detailed histories of previous violence and other risk factors.
Finally, in the event that a violence risk assessment may be required in primary
care, the GDG concluded that a history of previous violence should be taken and
referral to specialist services should be considered.
Primary care services

6.2.8.1 Assessing risk of violence is not routine in primary care, but if such assess-
ment is required consider:
● current or previous violence, including severity, circumstances, precip-
itants and victims
● the presence of comorbid mental disorders and/or substance misuse
● current life stressors, relationships and life events
● additional information from written records or families and carers
(subject to the person’s consent and right to confidentiality), because
the person with antisocial personality disorder might not always be a
reliable source of information.
6.2.8.2 Healthcare professionals in primary care should consider contact with
and/or referral to secondary or forensic services where there is current
violence or threats that suggest significant risk and/or a history of serious
violence, including predatory offending or targeting of children or other
vulnerable people.
Secondary care services

6.2.8.3 When assessing the risk of violence in secondary care mental health serv-
ices, take a detailed history of violence and consider and record:
itants and victims
● contact with the criminal justice system, including convictions and
periods of imprisonment
● the presence of comorbid mental disorder and/or substance misuse
(subject to the person’s consent and right to confidentiality), as the
person with antisocial personality disorder might not always be a reli-
able source of information.
162
6.2.8.4 The initial risk management should be directed at crisis resolution and
ameliorating any acute aggravating factors. The history of previous
violence should be an important guide in the development of any future
violence risk management plan.
6.2.8.5 Staff in secondary care mental health services should consider a referral to
forensic services where there is:
● current violence or threat that suggests immediate risk or disruption to
the operation of the service
● a history of serious violence, including predatory offending or target-
ing of children or other vulnerable people.
Specialist personality disorder or forensic services

6.2.8.6 When assessing the risk of violence in forensic, specialist personality
disorder or tertiary mental health services, take a detailed history of
violence, and consider and record:
● current and previous violence, including severity, circumstances,
precipitants and victims
person with antisocial personality disorder might not always be a reli-
able source of information.
6.2.8.7 Healthcare professionals in forensic or specialist personality disorder services
should consider, as part of a structured clinical assessment, routinely using:
● a standardised measure of the severity of antisocial personality disor-
der (for example, PCL-R or PCL-SV)
● a formal assessment tool such as HCR-20 to develop a risk manage-
ment strategy.
6.3 RISK MANAGEMENT
6.3.1 Introduction
The priority for mental health services is arguably not risk assessment as much as risk
management. The task is not only to define and measure risk but to intervene in order
to reduce it. It is extremely rare for medical treatment to carry any third-party risk, so
it is essential that services take systematic action to reduce violence risk.
The key to effective risk management is the assessment of risk as a multi-faceted
construct using a descriptive approach rather than an estimate of high, medium or low
risk. A description of the nature of the risk, including the factors likely to increase or
decrease it, should lead seamlessly to a management plan.
163
6.3.2 Current practice
No formal evaluations or systematic reviews relating to violence risk management in

antisocial personality disorder were found.
6.3.3 Definition and aim of topic of review
Formal evaluation studies assessing interventions designed to manage the risk of

violence and/or offending were the subject of this review. Broad inclusion criteria
were adopted because there was initial interest in the capacity of the intervention to
manage risk of violence/offending behaviour, which is not exclusive to antisocial
personality disorder.
The review team conducted a new systematic search for observational studies on risk
management interventions that aimed to reduce the risk of violence and/or offending.
No studies that met the criteria of the review were identified. The GDG therefore
developed good practice recommendations based on a consideration of the risk
assessment literature including the National Confidential Inquiry into Suicide and
Table 27: Databases searched and inclusion/exclusion criteria for clinical

effectiveness of psychological interventions

Date searched Database inception to November 2007; table of
contents November 2007 to June 2008
Study design Observational studies
Patient population People with antisocial personality disorder; people in
psychiatric institutions; people in prison
Interventions Risk management interventions
Outcomes Reduction in risk of violence/offending
164
Homicide by People with Mental Illness (Appleby et al., 2006); professional consen-
sus; the recommendations of inquiries following homicides (Department of Health,
2007a); and recommendations produced by other bodies including the Risk
Management Authority Scotland (2006).
6.3.6 Essential features of a risk management plan
When considering the evidence for risk management, the GDG drew heavily on the
Department of Health (2007a) document, Best Practice in Managing Risk: Principles
and Evidence for Best Practice in the Assessment and Management of Risk to Self and
Others in Mental Health Services. This was developed by the Department of Health
as part of its National Mental Health Risk Management Programme. It includes 16
best practice points, which the GDG appraised as an effective synopsis of the current
best practice in risk management; these are summarised below (see Box 1).
Box 1: Best practice in risk management (Department of Health, 2007a)
Introduction
1. Best practice involves making decisions based on knowledge of the research
evidence, knowledge of the individual service user and their social context,
knowledge of the service user’s own experience, and clinical judgement.
Fundamentals
2. Positive risk management as part of a carefully constructed plan is a required
competence for all mental health practitioners.
3. Risk management should be conducted in a spirit of collaboration and based
on a relationship between the service user and their carers that is as trusting as
possible.
4. Risk management must be built on recognition of the service user’s strengths
and should emphasise recovery.
5. Risk management requires an organisational strategy as well as efforts by the
individual practitioner.
Basic ideas in risk management
6. Risk management involves developing flexible strategies aimed at preventing
any negative event from occurring or, if this is not possible, minimising the
harm caused.
7. Risk management should take into account that risk can be both general and
specific, and that good management can reduce and prevent harm.
8. Knowledge and understanding of mental health legislation is an important
component of risk management.
Continued
165
Box 1: (Continued)
9. The risk management plan should include a summary of all risks identified,
formulations of the situations in which identified risks may occur, and actions to
be taken by practitioners and the service user in response to crisis.
10. Where suitable tools are available, risk management should be based on
assessment using the structured clinical judgement approach.
11. Risk assessment is integral to deciding on the most appropriate level of risk
management and the right kind of intervention for a service user.
Working with service users and carers
12. All staff involved in risk management must be capable of demonstrating
sensitivity and competence in relation to diversity in race, faith, age, gender,
disability and sexual orientation.
13. Risk management must always be based on awareness of the capacity for the
service user’s risk level to change over time, and a recognition that each service
user requires a consistent and individualised approach.
Individual practice and team working
14. Risk management plans should be developed by multidisciplinary and multi-
agency teams operating in an open, democratic and transparent culture that
embraces reflective practice.
15. All staff involved in risk management should receive relevant training, which
should be updated at least every three years.
16. A risk management plan is only as good as the time and effort put into
communicating its findings to others.
These best practice points are general rather than specific but endorse the use of
structured clinical risk assessment in formulating risk management plans (as identi-
fied in Section 6.2.6). Many of the points are concerned with attitudes and expecta-
tions and it is worth considering how some of these general expectations can be
applied to the specific question of managing violence risk in antisocial personality
disorder.
Use of structured assessment tools

Structured assessments have increased value when they include a measure of the
severity of the personality disorder (usually the PCL-R or PCL-SV) because it is diffi-
cult to estimate severity by other clinical methods. Many of the predictive factors used
by risk assessment scales relate to the underlying construct of antisocial personality
disorder so they ought to be particularly useful in this condition.
166
Static and dynamic risk factors

While risk assessment relies heavily on static factors such as history of violence,
the management of risk depends on the manipulation of dynamic factors. The pres-
ence of static risk factors does not imply that a person cannot be treated or the
degree of risk modified. For example, even in the most severe personality disorder,
a considerable reduction in violence risk can often be achieved through treatment
of drug or alcohol problems, and through anger management (for a review of inter-
ventions for antisocial personality disorder see Chapter 7).
Multi-agency working
As risk depends in large part on what a person has already done, most high-risk
patients with antisocial personality disorder will already have been in contact with the
criminal justice system. Proper management of violence risk will rarely be a task for
mental health services alone. It is necessary to work with other disciplines and in
many cases health will not be the lead agency.
Admission to hospital
Admission to hospital is rarely an appropriate treatment for antisocial personality
disorder. The main exceptions are at times of crisis, when the admission should have
a clearly defined purpose and end point; for the treatment of comorbid conditions (for
example, severe depression with a serious associated risk of suicide); and in
specialised services for patients who present particularly high risks that cannot be
safely managed by other means.
Supervision and treatment in the community

Although its manifestations fluctuate over time, antisocial personality disorder is
a lifelong condition and the key to successful risk management is often a long-
term supportive, therapeutic relationship, which may involve more than one
agency. In high-risk cases the supervision may be mandatory but compulsion
should be seen as a step towards developing a therapeutic relationship rather than
a substitute for it.
The recommendations that follow draw on three sources of evidence: the review of
specialist assessment tools (an influential factor in the decision to identify specific
measures in addition to their psychometric properties was their current use in the UK
and their ability to inform a risk management plan; see Section 6.2.6); other guidance
on the treatment and management of antisocial personality disorder; and the expert
opinion of the GDG. The GDG used methods of informal consensus to arrive at the
recommendations.
167
6.3.8.1 Services should develop a comprehensive risk management plan for people
with antisocial personality disorder who are considered to be of high risk.
The plan should involve other agencies in health and social care services
and the criminal justice system. Probation services should take the lead
role when the person is on a community sentence or is on licence from
prison with mental health and social care services providing support and
liaison. Such cases should routinely be referred to the local Multi-Agency
Public Protection Panel.
168
Interventions for people with antisocial personality disorder
7 INTERVENTIONS FOR PEOPLE WITH

AND ASSOCIATED SYMPTOMS AND
BEHAVIOURS
7.1 INTRODUCTION
Both psychological and pharmacological interventions for people with antisocial

personality disorder are poorly researched and direct evidence on the treatment of this
population is scarce. Three relatively recent reviews failed to identify any high-quality
evidence for people receiving treatment for antisocial personality disorder (Salekin,
2002; Warren et al., 2003; Duggan et al., 2007a).
A number of approaches have been adopted to address this problem: the use of
lower quality evidence, including evidence such as case studies and case series (for
example, Salekin, 2002); the use of research on other personality disorders or mixed
populations of people with personality disorder including a proportion with antisocial
personality disorder, usually a relatively small proportion (for example, Warren et al.,
2003); and consideration of the impact of treatments for comorbid problems (such as
drug misuse) in antisocial personality disorder populations (Duggan et al., 2007a).
All three approaches are problematic in guiding treatment choice for antisocial
personality disorder because of difficulties understanding causality (Salekin, 2002),
lack of generalisability (Warren et al., 2003), and the lack of direct evidence for the
treatment of the disorder itself (Duggan et al., 2007a).
In order to address these limitations, the GDG opted to identify the best available
evidence on:
(i) the treatment of people with antisocial personality disorder – this was to ensure
that new studies or studies excluded by other reviews could be considered
(ii) the treatment of specific components of the diagnostic construct of antisocial
personality disorder (for example, impulsivity and aggression) – this was to
include important evidence on the treatment of a particular aspect of antisocial
(iii) interventions for offenders that aim to reduce re-offending – this was consid-
ered important because offending and related behaviours are both key to the
difficulties associated with antisocial personality disorder.
The GDG recognised that the inclusion of evidence for offending behaviour was
potentially controversial and that offending behaviour might be seen as a poor proxy
outcome in the treatment of antisocial personality disorder. The rationale for using
offending behaviour as a proxy for a diagnosis of antisocial personality disorder
(where the latter has not been recorded) is threefold. First, a history of antisocial
169
behaviour is a particular feature of antisocial personality disorder in the DSM-IV

diagnostic system (APA, 2000), specifically the ‘failure to conform to social norms
with respect to lawful behaviours as indicated by repeatedly performing acts that are
grounds for arrest’. Second, interventions aimed at reducing offending behaviour
often focus on other diagnostic criteria of antisocial personality disorder as mediat-
ing variables in the treatment process. To date, such work has included studies of
impulsivity, aggressiveness, and lack of remorse as ‘treatment targets’. Therefore,
evidence that has a bearing on the amelioration of these factors is also potentially
relevant to the treatment of antisocial personality disorder. Third, surveys of offend-
ers very often find high rates of personality disorder that are significantly above the
levels found in community-based studies of prevalence, in particular among those
who are imprisoned and those with entrenched patterns of more serious offences. As
noted earlier, a survey for the UK Office for National Statistics interviewed 3,142
prisoners and found that 49% of male sentenced prisoners, 63% of males on remand,
and 31% of female prisoners met criteria for diagnosis of antisocial personality
disorder (Singleton et al., 1998).
7.1.1 Treatment of comorbid disorders
Given the limited evidence for the treatment of antisocial personality disorder and
that guidance on disorders commonly comorbid with antisocial personality disorder
generally does not consider the impact of antisocial personality disorder on treatment
recommendations, the GDG decided to review the evidence for the treatment of
comorbid disorders. The evidence on the treatment of comorbid disorders was
restricted to populations with antisocial personality disorder, and evidence was not
extrapolated from studies of offenders or other populations. In the review of interven-
tions for offending behaviour, the GDG also decided to include studies of interven-
tions for drug and alcohol misuse and dependence in offender populations where such
studies met quality criteria.
7.2 PSYCHOLOGICAL INTERVENTIONS FOR ANTISOCIAL

7.2.1 Introduction
There has been little formal development of psychological interventions specifically

for the treatment of antisocial personality disorder with considerably more emphasis
placed on the psychological treatment of other personality disorders, primarily
borderline personality disorder (for example, Kernberg, 1984; Linehan, 1997). As
with personality disorder more generally, psychoanalytic approaches to treatment
held sway initially (Cordess & Cox, 1998); more recently developments in cognitive
behavioural treatments have emerged but such approaches in antisocial personality
disorder are not supported by a strong evidence base (Duggan et al., 2007a).
170
Psychological interventions for comorbid disorders are, by contrast, well developed

and are as effective or more effective than pharmacological treatments for common
mental disorders (for example, NCCMH, 2005a, 2005b, 2006). This suggests that
such interventions may have a significant role to play in the treatment of comorbid
disorders in antisocial personality disorder. Similarly effective psychological treat-
ments for drug and alcohol disorders have also been developed (NCCMH, 2007a) and
may again be of benefit to people with antisocial personality disorder with comorbid
drug and alcohol problems.
Although psychological interventions specifically for antisocial personality
disorder are limited, interventions for some of the components of the antisocial
personality disorder diagnostic construct have been better developed, principally for
the treatment or management of aggression. However, the relevance of anger
management as an intervention for an aspect of the antisocial personality disorder
diagnostic construct may be limited. Anger is not explicitly included in the diagnos-
tic criteria for antisocial personality disorder and while anger may be related to
impulsivity and aggression, reducing anger may not reduce impulsivity and aggres-
sion. Equally, when delivered to offenders, anger management interventions may
reduce levels of anger without having an impact on offending, aggressive or violent
behaviours if the causes of those behaviours in an individual are unrelated to anger.
The majority of literature on anger management has focused on populations of
college students (Edmonson & Conger, 1996; Del Vecchio & O’Leary, 2004; Beck
& Fernandez, 1998). The GDG felt that it would not be appropriate to extrapolate
from college students with elevated levels of anger to people with antisocial person-
ality disorder. As a consequence, this review is not concerned with the efficacy of
anger management in these populations.
In contrast to the limited development of specific treatment for antisocial person-
ality disorder, there has been considerable development of interventions aimed at
reducing offending behaviour. These include a wide range of cognitive and behav-
ioural interventions (for example, Landenberger & Lipsey, 2005; Lipsey et al., 2001,
2007; Lipton et al., 2002; Tong & Farrington, 2006; Wilson et al., 2005), and to a
lesser extent therapeutic communities (Lees et al., 2003). Within the UK criminal
justice system the use of cognitive and behavioural interventions such as Reasoning
and Rehabilitation (for example, Cann et al., 2003) and Enhanced Thinking Skills
(for example, Friendship et al., 2002) is widespread.
Current practice
Healthcare services
Most people with antisocial personality disorder in the community remain undiag-
nosed and untreated (Department of Health, 2003). They do not come into contact
with mental health services and often do not perceive any need for treatment of their
personality problems. Some people with the disorder may seek treatment for comor-
bid mental health disorders, including anxiety and depression, but whether they have
a formal diagnosis of antisocial personality disorder or not, they may nevertheless be
excluded from services because of their personality disorder or the mistaken belief
171
that they will not be able to benefit from treatment. People with antisocial personal-
ity disorder may also make limited use of inpatient services in a crisis but are unlikely
to be offered or engage in long-term treatment.
In contrast to mental health services, a significant number of people with antiso-
cial personality disorder are treated by drug and alcohol services in both the statutory
and non-statutory sector. Here the focus on treatment will be on the drug or alcohol
misuse not the personality problem.
Health services treating people specifically for their antisocial personality disor-
der are largely limited to specialist healthcare services such as forensic services.
However, even within forensic services specific provision for antisocial personality
disorder is underdeveloped. At the very severe end of the spectrum the recent devel-
opment of the Dangerous and Severe Personality Disorder Service (Home Office,
1997) has seen the establishment of new units in two special hospitals (Rampton and
Broadmoor) and two high secure prisons (HMP Frankland and HMP Whitemoor).
The criminal justice system

The large majority of people receiving interventions for antisocial personality
disorder and related problems will be in the criminal justice system, with the inter-
ventions provided either by the probation or prison services. The explicit aim of
these interventions is to reduce offending behaviour. These interventions are
highly manualised and subject to stringent quality assurance and auditing (T3
Associates, 2003). Whether individuals in the criminal justice system receive
interventions will depend on a range of factors including the availability of places
on offending behaviour programmes in the institution or probation service, the
type and length of their sentence (as this may or may not facilitate their enrolment
in a programme), and, if they are in prison, whether they voluntarily choose to
enrol on a programme.
The majority of psychological interventions delivered in the criminal justice
system are cognitive behavioural and largely based on social learning theory, a devel-
opment of behavioural learning models that has been adapted to take account of find-
ings from cognitive and developmental psychology (Bandura, 2001). These
interventions include: behaviour modification; relaxation training; systematic desen-
sitisation; social skills training; problem-solving therapy; cognitive therapy; and
moral reasoning or moral reconation therapy. Virtually all of these methods have been
employed in efforts to reduce offending behaviour and this represents the largest
research base of evidence for interventions with offenders. The literature has been
reviewed in a number of meta-analyses (for example, Lipton et al., 2002;
Landenberger & Lipsey, 2005; Tong & Farrington, 2006; Lipsey et al., 2007).
Beyond the health and criminal justice system interventions, the provision of care
and support for people with antisocial personality disorder is also very limited. As
they may cause disruption and a threat to staff or other services users, people with
antisocial personality disorder may find themselves excluded from a range of services
that might otherwise support them in the community (including during transition
from the care of the criminal justice system to the community), such as housing,
welfare and employment services.
172
The review considered psychological interventions for antisocial personality disorder

and its constructs. This included interventions for people specifically diagnosed with
antisocial personality disorder, but also interventions for the symptoms or behaviours
associated with this diagnostic construct including anger, impulsivity and aggression.
However, studies of populations with diagnoses of serious mental illness (including
schizophrenia) were excluded. In addition, interventions for offending behaviour in
people without a diagnosis of antisocial personality disorder were considered, includ-
ing for offenders with substance misuse problems.
Outcomes
For the review of the effectiveness of interventions for adults with antisocial person-
ality disorder, the GDG chose re-offending as the primary outcome. There are a
number of measures of re-offending including conviction, arrest, breaches of condi-
tions attached to parole or probation, re-incarceration and recidivism. Conviction was
considered the most robust measure but where this was not reported other re-offend-
ing outcomes were extracted in the order of priority listed above.
this section of the guideline can be found in Table 28 (further information about the
search for health economic evidence can be found in Appendix 11.)
The review team conducted a series of systematic searches for RCTs that assessed
the efficacy and cost effectiveness of psychological interventions specifically for the
Table 28: Databases searched and inclusion/exclusion criteria

for clinical evidence
Electronic databases MEDLINE, EMBASE, PsycINFO, Cochrane Library,

C2-SPECTR, NCJRS, IBSS, FEDRIP
Study design RCT
Patient population People with antisocial personality disorder, people with
behaviour or symptoms associated with the antisocial
personality construct, offending behaviour
Interventions Psychological interventions
Outcomes Offending, reduction in impulsivity, anger or aggression
173
treatment of antisocial personality disorder, behaviours or symptoms associated with

the antisocial personality disorder construct, and offending behaviour (see Table 31).
One trial (DAVIDSON2008) met the eligibility criteria of the GDG in the first
systematic search to assess the treatment of antisocial personality disorder.
Two further searches were conducted separately on behaviours and symptoms asso-
ciated with the antisocial personality disorder construct, and on offending behaviour.
A total of 22 trials relating to clinical evidence met the eligibility criteria set by the
GDG, providing data on 3,237 participants. Of these, two trials were reported in books
(JOHNSON1995, PORPORINO1995), two were reports from the US Department of
Justice (AUSTIN1997, PULLEN1996), and 18 were published in peer-reviewed jour-
nals between 1973 and 2008 (ARMSTRONG2003, DAVIDSON2008, DEMBO2000,
DUGAN1998, ELROD1992, GREENWOOD1993, GUERRA1990, KINLOCK2003,
LEEMAN1993, LIAU2004, OSTROM1971, ROHDE2004, ROSS1988,
SCHLICHTER1981, SHIVRATTAN1988, SPENCE1981, VAN VOORHIS2004,
VANNOY2004). In addition, 97 studies were excluded from the analysis. The most
common reason for exclusion was lack of a comparison group (further information
about both included and excluded studies can be found in Appendix 15).
For the treatment of people with antisocial personality disorder, there was one trial
(DAVIDSON2008) that met the eligibility criteria of the review providing informa-
tion on 39 participants.
For the treatment of people with symptoms or behaviour associated with the anti-
social personality disorder construct, there was one trial that investigated the treat-
ment of anger by comparing anger management with control (VANNOY2004).
For the treatment of offending behaviour in adults with substance misuse prob-
lems, there were four trials investigating cognitive and behavioural interventions,
three of which were group-based interventions (AUSTIN1997; JOHNSON1995;
KINLOCK2003) and one which was individually based (DUGAN1998).
For the treatment of offending behaviour in adults, there were five trials comparing
group-based cognitive and behavioural interventions with control (ARMSTRONG2003;
LIAU2004; PORPORINO1995; ROSS1988; VANVOORHIS2004).
For the treatment of offending behaviour in young people, seven trials compared
group-based cognitive and behavioural skills interventions with control (GUERRA1990;
LEEMAN1993; OSTROM1971; PULLEN1996; ROHDE2004; SCHLICHTER1981;
SPENCE1981); one trial was on individual cognitive and behavioural interventions
(SHIVRATTAN1988) and three trials compared multi-component interventions with
control (ELROD1992; GREENWOOD1993; DEMBO2000).
11Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capi-
ted for publication, then a date is not used). The references for studies can be found in Appendix 15.
174
7.2.5 Clinical evidence for the treatment of antisocial personality disorder
The search identified one study relating to the treatment of antisocial personality
disorder (DAVIDSON2008). The study compared CBT with treatment as usual for
people with antisocial personality disorder living in the community (see Table 29 and
Table 30). Full study characteristics and forest plots can be found in Appendices 15
and 16 respectively.
DAVIDSON2008 did not find an effect for CBT on anger or verbal aggression
compared with treatment as usual for people with antisocial personality disorder
in the community. The trial did find a small, non-significant effect for social function-
ing and physical aggression compared with treatment as usual.
7.2.6 Clinical evidence summary for the treatment of antisocial

The evidence for the treatment of antisocial personality disorder in the community is
limited to one trial. The quality of the evidence is low to moderate where further
research is likely to have an impact on the effect estimate of CBT in the community
for people with antisocial personality disorder. The limited economic evidence from
this trial suggests that CBT may not be cost saving in the short term (see below).
7.2.7 Economic evidence for the treatment of antisocial personality disorder
One economic study on psychological treatment of antisocial personality disorder

was included in the systematic economic literature review (Davidson et al., 2008).
Table 29: Study information table on CBT for treatment of antisocial

Cognitive behavioural therapy versus treatment as usual for antisocial

Total no. of trials (total no. 1 RCT
of participants) (N = 52)
Study ID DAVIDSON2008
Population People with antisocial personality disorder
Setting Community
Treatment length 6–12 months
Length of follow-up 12 months
175
Table 30: GRADE evidence summary for interventions for antisocial

CBT compared with treatment as usual for people with antisocial personal-
ity disorder in the community
Population: antisocial personality disorder
Settings: community
Intervention: CBT versus treatment as usual
participants the evidence
(studies) (GRADE)
Novaco Anger 39 丣丣 SMD −0.06

Scale - Total (1) low1,2,3 (−0.69 to 0.56)
Novaco Anger Scale - 39 丣丣 SMD −0.18

Provocation Inventory (1) low1,2,3 (−0.81 to 0.45)
(subscale)
Social Functioning 39 丣丣丣 SMD −0.27

Questionnaire (1) moderate2,3 (−0.9 to 0.36)
Aggression (ITT) - 52 丣丣丣 RR 0.94

Verbal aggression (1) moderate2,3 (0.73 to 1.21)
Aggression (ITT) - 52 丣丣丣 RR 0.77

Physical aggression (1) moderate2,3 (0.42 to 1.41)
1 Outcome is not directly relevant to antisocial personality disorder
2 Data sparse
3 Effect compatible with benefit and no benefit
The study, which was conducted in the UK, was a simple cost analysis of CBT plus
treatment as usual versus treatment as usual alone conducted alongside an RCT
included in the guideline systematic review of clinical evidence (DAVIDSON2008).
The study examined healthcare costs (including psychiatric care, accident and emer-
gency visits and primary care), social work costs and costs borne by the criminal
justice system. The time horizon of the analysis was 12 months. Overall, the total cost
per person in the CBT group was higher than the respective cost in the treatment as
usual group (£38,004 versus £31,097, respectively). The healthcare cost was similar
in both groups (£1,295 in the CBT group and £1,133 in the TAU group). The cost of
providing CBT was £1,300 per participant. Details on the methods used in the
systematic review of the economic literature are described in Chapter 3. Evidence
176
tables for all economic studies included in the guideline economic literature review
are in Appendix 14.
7.2.8 Clinical evidence for the treatment of the constructs of antisocial

One trial relating to clinical evidence for the treatment of the constructs of antisocial
personality disorder met the eligibility criteria set by the GDG, providing data on 31
participants (VANNOY2004). The included study was a trial of group-based anger
management versus waitlist in an offender population. This small study reported data
only on a continuous measure and was considered to be of low quality. The outcomes
of the trial were trait anger (STAXI; SMD ⫺0.64, ⫺1.36 to 0.09) and state anger
(STAXI; SMD ⫺0.96, ⫺1.70 to ⫺0.21).
7.2.9 Clinical evidence summary for the treatment of the constructs of

The evidence for the treatment of the constructs of antisocial personality disorder is
extremely limited and does not support the development of any recommendations.
7.2.10 Economic evidence for the treatment of the constructs of antisocial

No evidence on the cost effectiveness of treatment of the constructs of antisocial

personality disorder was identified by the systematic search of the literature. Details
on the systematic search of the literature are provided in Chapter 3.
7.2.11 Clinical evidence for the treatment of offending in substance misuse

offenders
The review found four trials that investigated cognitive and behavioural interventions
for the treatment of offending in substance misuse offenders, three of which were
group based interventions (AUSTIN1997; JOHNSON1995; KINLOCK2003) and
one was individually based (DUGAN1998). This review provided data on 582 partic-
ipants (see Table 31 and Table 32). Full study characteristics and forest plots can be
found in Appendices 15 and 16 respectively.
For the treatment of offending in substance misuse offenders, the five included
studies were identified as cognitive and behavioural interventions. The review found
this intervention to have a medium effect on offending and major infractions
combined (RR ⫽ 0.76; 0.60, 0.97) and a small non-significant effect on mean number
of offences (SMD 0.19; ⫺0.18 to 0.55).
177
Table 31: Study information table for group-based cognitive and behavioural
intervention compared with non-treatment control for substance misuse offenders
Group-based cognitive and behavioural intervention compared with non-

treatment control
Total no. of trials (total no. 4 RCTs
of participants) (N = 426)
Study ID AUSTIN1997
DUGAN1998
JOHNSON1995
KINLOCK2003
Population Offenders with substance misuse problems
Setting Institution (prison):
DUGAN1998
KINLOCK2003
Community (probation):
AUSTIN1997
JOHNSON1995
Average treatment length 114 days
Length of follow-up Longest follow-up: 1 year
7.2.12 Clinical evidence summary for the treatment of offending in

substance misuse offenders
There appears to be modest evidence for the effectiveness of cognitive and behav-
ioural interventions, primarily delivered in groups, in reducing offending for adults
with substance misuse problems. This effect has been found in a variety of settings
including institutional prison-based settings and outpatient and probation settings in
the community.
7.2.13 Economic evidence for the treatment of offending in substance

misuse offenders
One study met the inclusion criteria for the systematic economic literature review
(Alemi et al., 2006). The study, which was conducted in the US, compared the costs
over 2.75 years of a combination of probation and substance misuse treatment versus
178
Table 32: GRADE evidence summary for the treatment of offending in

substance misuse offenders
Group-based cognitive and behavioural intervention compared with non-

treatment control for substance misuse offenders
Population: substance misuse offenders
Settings: prison, probation and outpatient
Intervention: cognitive and behavioural interventions versus control
Outcomes No. of Quality of
(studies) (GRADE) Comments
Any bad antisocial personality 394 丣丣丣 RR 0.78

disorder outcome (3) moderate1 (0.58 to 1.04)
[dichotomous] - Re-offending
Any bad antisocial personality 160 丣丣 RR 0.74

disorder outcome (1) low1,2,3 (0.49 to 1.11)
[dichotomous] - Major
infractions
Mean number of offences 117 丣丣 SMD 0.19

(1) low1,2,3 (⫺0.18 to 0.55)
1 Population does not directly involve antisocial personality disorder
2 Sparse data
3 Effect is compatible with benefit and no benefit
probation alone. Overall, a combination of probation and treatment was $6,300 more
expensive than traditional probation per participant annually, mainly because of
greater mental hospitalisation and additional treatment costs. The study characteris-
tics and results are presented in the form of evidence tables in Appendix 14. Details
on the systematic search of the economic literature are provided in Chapter 3.
7.2.14 Clinical evidence for the treatment of offending behaviour in adults
There were five trials comparing the effects of group-based cognitive and behavioural
interventions with control on re-offending for adult offenders treated within the crim-
inal justice system (institutional settings or in the community on probation or parole)
(see Table 33 and Table 34). Conviction was considered the most robust measure of
re-offending but where this was not reported, other re-offending outcomes were
179
Table 33: Study information table for group-based cognitive and behavioural
interventions for offenders
Group-based cognitive and behavioural intervention versus non-treatment

control
Total no. of trials (total no. 5 RCTs (N ⫽ 1798)

of participants)
Study ID ARMSTRONG2003
LIAU2004
PORPORINO1995
ROSS1988
VANVOORHIS2004
Population Offenders
Setting Institution (prison):
ARMSTRONG2003
PORPORINO1995
Community (probation):
ROSS1988
VANVOORHIS2004
In between institution and probation (halfway house):

LIAU2004
Average treatment length 115 days
Length of follow-up Longest follow-up: 9 months
Age 18–20 years:
ARMSTRONG2003
20+ years:
LIAU2004
PORPORINO1995
ROSS1988
VANVOORHIS2004
extracted (for further details see Section 7.2.2). Full study characteristics and forest
plots can be found in Appendices 15 and 16 respectively.
Group-based cognitive and behavioural interventions were found to provide a
modest effect on re-offending (RR 0.78; 0.55 to 1.08). The population included in this
analysis was predominantly adult male offenders. LIAU2004, which included a small
180
Table 34: GRADE evidence summary for group-based cognitive and

behavioural intervention for offenders
Group-based cognitive and behavioural intervention versus non-treatment

control
Patient or population: Offenders
Settings: Prison/institutional and probation/parole
Intervention: Cognitive and behavioural intervention for offenders
Comparison: Untreated comparison
Outcomes No. of Quality of Relative
participants the evidence effect
(studies) (GRADE) (95% CI)
Re-offending - inclusive 1270 丣丣 RR 0.78

measures [male and mixed (5) low1,2 (0.55 to 1.08)
offenders] – ITT data only
Re-offending [young male 212 丣丣 RR 1.00

offenders, age range or (1) low2,3 (0.82 to 1.22)
mean 18–20] – ITT
data only
1 Some of the heterogeneity is explained by one study
2 Population is not directly ASPD
3 Effect compatible with benefit and no benefit
proportion of female offenders, was not included in the meta-analysis because it was
not possible to extract intention-to-treat (ITT) data.
7.2.15 Clinical evidence summary for the treatment of offending behaviour

in adults
There appears to be modest evidence for the effectiveness of group-based cognitive

behavioural skills interventions, delivered in community and institutional settings, in
reducing offending for adults in the criminal justice system.
Group-based cognitive behavioural skills interventions for offending behaviour
delivered to offenders in criminal justice settings (prison/institutional settings and
probation/parole) have a small but positive effect on the rate of re-offending for adult
male offenders aged 21 and over. However, the more limited evidence base on young
adult offenders aged 18 to 20 indicates that young offenders do not respond to these
interventions.
181
7.2.16 Health economic evidence for the treatment of offending behaviour
Systematic literature review

One US study focusing on interventions targeted at adult offenders was identified by
the systematic search of economic literature (Zhang et al., 2006). The study evaluated
a state-wide multiple community-based services parole programme in California by
comparing programme costs with incarceration costs avoided because of decreases in
recidivism. Over 2 years, programme participants had lower recidivism and reincar-
ceration rates than the untreated population, resulting in significant net savings of $21
million.
Economic modelling
Objective
The guideline systematic review and meta-analysis of clinical evidence demon-
strated that provision of Reasoning and Rehabilitation, a group-based cognitive
behavioural skills intervention (Cann et al., 2003), to adult offenders can potentially
reduce the rates of future offending behaviour. Offending behaviour leads to substan-
tial costs to the society, including the criminal justice system and victims of crime.
A cost analysis was undertaken to assess whether the costs to the NHS of providing
Reasoning and Rehabilitation to adults with offending behaviour are offset by future
cost savings resulting from reduction in re-offending behaviour in this population.
Methods
Intervention examined Reasoning and Rehabilitation programmes are offered to
people with offending behaviour in institutional and community correctional settings.
They typically consist of 38 curriculum-based sessions of 2 hours’ duration each over
approximately 8 to 12 weeks. Programmes are delivered to small groups of eight to
ten participants (T3 Associates, 2003).
Costs considered in the analysis A simple economic model was developed to estimate
the net total costs (or cost savings) associated with provision of Reasoning and
Rehabilitation to adult offenders. Published evidence on the costs incurred by adults
with offending behaviour is limited. One study conducted in the UK that assessed the
effectiveness of CBT in adults with antisocial personality disorder reported 12-month
service costs incurred by this population, including healthcare, social work and
criminal justice system costs (Davidson et al., 2008). The total costs per adult with
antisocial personality disorder receiving CBT over 12 months were £38,000. Of
these, only 7% were healthcare costs (including provision of CBT); the vast majority
of costs were associated with social work and use of criminal justice system services.
NICE recommends that economic analyses of healthcare interventions adopt a
NHS and PSS perspective (NICE, 2006a). However, the criminal justice system and
social and other public services are likely to bear the majority of costs incurred by
adults with offending behaviour and only a small proportion of costs fall on the NHS
and PSS. For this reason, the economic analysis adopted a broader perspective than
182
that of the NHS and PPS, including any costs to public services for which appropri-
ate information was available.
Existing clinical evidence suggests that provision of Reasoning and Rehabilitation
to adults with offending behaviour may reduce rates of re-offending, and therefore
costs relating to crime. It is unknown whether participation of adult offenders in such
programmes has an effect on other costs, such as costs to health and social care serv-
ices, although it is likely that reducing offending behaviour may result in a decrease
in other costs too. Because of lack of appropriate relevant data that could inform the
economic model, the analysis has considered only intervention costs (that is, costs of
providing Reasoning and Rehabilitation) and costs related to crime/adult offending
behaviour. All other categories of public sector costs, such as health and social care
costs, were conservatively assumed to be the same for adult offenders participating in
Reasoning and Rehabilitation programmes and for those not receiving the intervent-
ion, and were subsequently omitted from the analysis. This is acknowledged as a
limitation of the economic analysis. However, costs relating to crime are likely to
constitute the most substantial part of the costs incurred by adult offenders; therefore,
the economic analysis is likely to have considered the majority of costs associated
with providing Reasoning and Rehabilitation to adults with offending behaviour.
Model input parameters
Clinical efficacy of Reasoning and Rehabilitation and baseline re-offending rate

in adult offenders
Clinical data on re-offending rates associated with Reasoning and Rehabilitation were
taken from three studies (PORPORINO1995; ROSS1988; VAN VOORHIS2004).
Meta-analysis of these data undertaken for the guideline showed that the intervention
reduced the rate of re-offending in adult offenders compared with no treatment, but
results were non-statistically significant at the 0.05 level (mean RR of re-offending
for Reasoning and Rehabilitation versus control: 0.78; 95% CI: 0.55 to 1.08). These
results were characterised by considerably high heterogeneity caused by inclusion of
ROSS1988 in the meta-analysis. When this study was removed, there was no hetero-
geneity in the results but the effect of the intervention was reduced (mean RR of
re-offending for Reasoning and Rehabilitation versus control: 0.88; 95% CI: 0.75 to
1.03). Details of the clinical studies considered in the economic analysis are available
in Appendix 15. The forest plots of the respective meta-analyses are provided in
Appendix 16.
The baseline re-offending rate for adults with previous offending behaviour was
taken from a national report containing 12-month data on re-offending for adults
released from custody or commencing a court order (sentences under probation
supervision excluding fines) in England and Wales in 2006 (Ministry of Justice,
2008a). According to this document, the re-offending rate in this population was 39%
over 12 months. This rate was determined by the number of offenders in the cohort
offending at least once during the 12-month follow-up period, where the offence
resulted in a court conviction or an out-of-court disposal. The 12-month rate of adult
re-offending following provision of Reasoning and Rehabilitation in the economic
183
analysis was calculated by multiplying the estimated RR of re-offending of the inter-

vention versus control by the baseline re-offending rate.
Intervention costs (costs of providing the Reasoning and Rehabilitation

programme)
In order to estimate total intervention costs, relevant resource use was estimated and
combined with respective unit costs. Resource use estimates associated with provi-
sion of a Reasoning and Rehabilitation programme were adopted from T3 Associates
(2003) and were consistent with resource use described in studies providing the effi-
cacy data for this analysis. According to these estimates, the evaluated intervention
consisted of 38 sessions lasting 2 hours each, delivered to groups of eight adults with
offending behaviour.
The unit cost of therapists providing Reasoning and Rehabilitation was assumed
to equal that of clinical psychologists (Band 7) due to lack of more relevant unit cost
estimates. However, it is recognised that therapists providing Reasoning and
Rehabilitation may be on a lower salary scale, and therefore the total intervention cost
may have been overestimated. The national unit cost of clinical psychologists has
been estimated at £67 per hour of client contact in 2006/07 prices (Curtis, 2007). This
estimate was based on the mid-point of Agenda for Change salaries Band 7 of the
April 2006 pay scale according to the National Profile for Clinical Psychologists,
Counsellors and Psychotherapists (NHS, 2006). It includes salary, salary on costs,
overheads and capital overheads but does not take into account qualification costs as
the latter are not available for clinical psychologists.
Based on the above resource use estimates and the unit cost of clinical psycholo-
gists, the cost of providing the Reasoning and Rehabilitation programme was esti-
mated at £637 per adult with offending behaviour at 2006/7 prices.
Costs of adult offending behaviour/cost savings from reducing adult

re-offending rates
In order to estimate the annual cost resulting from re-offending behaviour by adult
offenders, three types of data are needed:
● proportion of different types of offences committed by adult re-offenders
● costs associated with each type of offence
● number of offences per adult re-offender per year.
Data on the proportion of different types of offences committed by adult
re-offenders in England and Wales were derived from a national report published by
the Ministry of Justice (2008a). The same document reported that the number of
offences per adult re-offender were 3.742 over 12 months.
Costs associated with each type of offence committed by adult offenders were
taken from a variety of sources, as reported in Chapter 5, Section 5.4.14. Costs were
uplifted to 2007 prices using the Retail Prices Index (Office for National Statistics,
2008). The cost per offence committed by adult re-offenders was estimated as the
mean cost of all offences weighted by the proportion of offences committed on
average by an adult re-offender. Table 35 shows the percentage of offences
committed by adult re-offenders, the cost of each type of offence as estimated in
184
Table 35: Percentage and costs of offences committed by adult re-offenders
Type of offence Percentage1 Cost (£, 2007 Source of cost

prices)
Violence (serious) 0.38 45,686 Dubourg & Hamed, 2005
Violence (non serious) 10.80 9,180 Dubourg & Hamed, 2005
Robbery 0.67 8,298 Dubourg & Hamed, 2005
Public order or riot 7.76 1,671 Godfrey et al., 2002
Sexual 0.40 35,825 Dubourg & Hamed, 2005
Sexual (child) 0.04 35,825 Dubourg & Hamed, 2005
Soliciting or prostitution 0.12 1,671 Godfrey et al., 2002
Domestic burglary 1.94 3,724 Dubourg & Hamed, 2005
Other burglary 2.61 3,373 Brand & Price, 2000
Theft 25.45 722 Dubourg & Hamed, 2005
Handling 1.28 1,671 Godfrey et al., 2002
Fraud and forgery 1.88 1,874 Brand & Price, 2000
Absconding or bail offences 10.22 1,671 Godfrey et al., 2002
Taking and driving away and 1.68 4,715 Dubourg & Hamed, 2005
related offences
Theft from vehicles 1.69 978 Dubourg & Hamed, 2005
Other motoring 16.00 1,840 Department of Transport, 2007
offences
Drink driving 1.98 200 Assumption
Criminal or malicious damage 5.25 987 Dubourg & Hamed, 2005
Drugs import/export/production/ 0.84 4,308 Godfrey et al., 2002
supply
Drugs possession/small scale 4.86 1,671 Godfrey et al., 2002
supply
Other 4.14 1,500 Assumption
TOTAL 100.00 2,706†
1 Source: Ministry of Justice, 2008a; †Total weighted cost (100.00)
the literature, and the weighted average cost per offence committed by adult
re-offenders.
The average cost per offence committed by adult re-offenders was estimated at
£2,706. Since this population commits 3.742 offences over 12 months (Ministry of
Justice, 2008a), the 12-month cost associated with offending behaviour is £10,127 per
adult re-offender.
185
Time horizon of the analysis

The three studies included in the guideline meta-analysis of clinical data on Reasoning
and Rehabilitation had time horizons ranging between 4 and 9 months. It is not known
whether the beneficial effect of Reasoning and Rehabilitation lasts beyond 9 months.
Therefore, for the base-case analysis, a 1-year time horizon was chosen; alternative time
horizons up to 5 years were tested in sensitivity analysis, to explore the magnitude of
potential savings that could be gained if the intervention has a longer lasting effect.
Discounting
Costs incurred beyond 12 months were discounted at an annual rate of 3.5%, as recom-
mended by NICE (NICE, 2006a). Table 36 provides all input parameters utilised in the
base-case analysis of the economic model of Reasoning and Rehabilitation for adults
with offending behaviour.
Sensitivity analysis
One- and two-way sensitivity analyses were undertaken to explore the robustness of
the results under the uncertainty characterising some model input parameters. The
following scenarios were tested in sensitivity analysis:
● Use of the 95% CIs of the RR of re-offending of Reasoning and Rehabilitation
versus control.
● Exclusion of data from ROSS1988, which introduced heterogeneity in the meta-
analysis (resulting in a mean RR of re-offending of Reasoning and Rehabilitation
versus control: 0.88 with 95% CIs 0.75 to 1.03).
Table 36: Input parameters utilised in the economic model assessing the net
costs (or savings) resulting from provision of Reasoning and Rehabilitation
to adults with offending behaviour
Input parameters Value Source of data - comments
RR (95% CIs) of Reasoning 0.78 Guideline meta-analysis
and Rehabilitation (0.55 to 1.03)
versus control
Baseline re-offending rate 39% Ministry of Justice, 2008a
of adult re-offenders
(12 months)
Intervention cost per adult £637 Based on 38 sessions lasting 2 hours
each, delivered to groups of 8 adults
Weighted average cost per £2,706 See Table 35
offence committed by adult
re-offenders
Number of offences per adult 3.742 Ministry of Justice, 2008a
re-offender (12 months)
Annual discount rate 0.035 NICE, 2006a
186
● Reduction in the baseline re-offending rate for adult offenders; an annual rate of
30% was tested.
● Extension of the time horizon of the analysis beyond 1 year; although currently
there is no evidence to suggest that Reasoning and Rehabilitation programmes
have a clinical effect lasting longer than 1 year, consecutive time horizons of 2 to
5 years were tested in sensitivity analysis to explore the magnitude of potential
cost savings achieved by provision of the intervention to adult offenders, if the
intervention has a longer lasting effect.
● Potential net savings accrued over 2 to 5 years were also estimated assuming that
the effect of the intervention was reduced over time; in this scenario the RR of
Reasoning and Rehabilitation versus control was multiplied by a factor of 1.15 for
every year after the first year following initiation of the intervention, to capture
this assumed decline in the clinical effect over time, until Reasoning and
Rehabilitation had no beneficial effect over control.
● Combination of alternative time horizons between 1 and 5 years with the rest of
the hypotheses described above.
In addition, threshold analyses identified the values of specific input parameters
where the results of the analysis were reversed. The parameters tested were the rela-
tive effect of Reasoning and Rehabilitation versus control (expressed in RR), the aver-
age cost of offence committed by adult re-offenders, and the baseline re-offending
rate of adults with offending behaviour over 12 months.
Results
Base-case analysis The reduction in the re-offending rates achieved by provision of
Reasoning and Rehabilitation to adult offenders yielded cost savings equalling £869
per adult with offending behaviour over 1 year. Because the provision of Reasoning
and Rehabilitation programmes costs £637 per adult offender, the intervention results
in an overall net saving of £232 per adult with offending behaviour over 1 year. Full
results of the base-case analysis are reported in Table 37.
Sensitivity analysis Results of the cost analysis were sensitive to the different
scenarios tested in sensitivity analysis. The results of meta-analysis (both including
and excluding ROSS1988) were not statistically significant at the 0.05 level and
Table 37: Results of economic analysis assessing the net costs (or savings)
resulting from provision of Reasoning and Rehabilitation to adults with
offending behaviour
Costs per adult (2007 prices) R&R Control Difference

Reasoning and Rehabilitation cost £637 0 £637
Cost of offending behaviour £3,081 £3,950 − £869
Total cost £3,718 £3,950 − £232
187
therefore using the upper 95% CI of the RR of the intervention versus control did not
lead to any savings because offending behaviour was in these cases increased
following provision of Reasoning and Rehabilitation to adult offenders. In all other
scenarios Reasoning and Rehabilitation resulted in net savings within the first year.
Although no long-term studies could demonstrate whether the beneficial effect of the
programme in reducing offending behaviour lasts beyond 1 year, sensitivity analysis
showed that, if such a longer effect exists, then the intervention could save on average
£3,424 per adult offender over 5 years (or £1,578, when ROSS1988 was excluded
from analysis).
Threshold analysis showed that the intervention became cost neutral over 1 year
when the cost per offence committed by adult offenders fell at £1,980, when the base-
line rate of re-offending was reduced at 29% over 12 months, and when the RR of the
intervention versus control was a maximum of 0.84.
Full results of one- and two-way sensitivity analyses are presented in Table 38.
In addition, threshold analyses identified the values of specific input parameters
where the results of the analysis were reversed. The parameters tested were the rela-
tive effect of Reasoning and Rehabilitation versus control (expressed in RR), the aver-
age cost of offence committed by adult re-offenders, and the baseline re-offending
rate of adults with offending behaviour over 12 months.
Discussion – limitations of the analysis

The results of the economic analysis indicate that Reasoning and Rehabilitation
programmes for adults with offending behaviour might be cost saving from a wide
economic perspective in the UK. The substantial intervention costs, resulting from
the high intensity of such programmes, could be offset by savings from a reduction
Table 38: Results of sensitivity cost analysis of providing Reasoning and

Rehabilitation to adults with offending behaviour
Scenario tested Net cost at different time horizons (2007 prices)

1 year 2 years 3 years 4 years 5 years
Meta-analysis of data from all
Reasoning and Rehabilitation studies
• Mean RR −£232 −£1,072 −£1,883 −£2,667 −£3,424
• Lower 95% CI −£1,141 −£2,858 −£4,517 −£6,120 −£7,669
• Upper 95% CI £952 £1,258 £1,553 £1,838 £2,113
Meta-analysis excluding ROSS1988
• Mean RR £163 −£295 −£738 −£1,165 −£1,578
• Lower 95% CI −£351 −£1,305 −£2,227 −£3,117 −£3,978
• Upper 95% CI £755 £869 £980 £1,087 £1,190
Baseline adult re-offending rate of 30% −£32 −£678 −£1,302 −£1,904 −£2,487
Increase in RR by 15% annually after −£232 −£625 −£625 −£625 −£625
1 year
188
in the rates of re-offending in adults. However, economic results were characterised by

uncertainty, as revealed in sensitivity analysis. This uncertainty was caused by the statis-
tical insignificance characterising the clinical data utilised in the economic model.
Although adult offenders incur a wide variety of costs, such as health and
social service costs and costs to the criminal justice system (Davidson et al.,
2008), the economic analysis considered only intervention costs and costs relating
to offending behaviour, owing to lack of evidence for a difference in other costs
between Reasoning and Rehabilitation and no treatment. Cost data on offending
behaviour were derived from several published sources reporting UK data and
included, in most cases, a wide range of costs, such as costs incurred in anticipa-
tion of offending behaviour, for example security expenditure, costs directly
resulting from offending, such as costs of stolen or damaged property, emotional
and physical impact on victims, costs of offering health and other services to
victims, as well as costs to the criminal justice system. Although it is acknowl-
edged that omission of other health and social care costs constitutes a limitation of
the analysis, existing evidence indicates that costs of offending behaviour are
probably the most significant costs incurred by adult offenders. Moreover, the
intervention reduces offending behaviour and this can potentially lead to a reduc-
tion in other costs such as healthcare costs and social benefit payments. If this is
the case, then the economic analysis has only underestimated the net savings
gained from Reasoning and Rehabilitation programmes. Moreover, some cost data
utilised in the economic analysis consisted exclusively of costs to the criminal
justice system. Other costs, such as healthcare costs and emotional distress of
victims, the financial and economic burden to the families of both victims and
offenders, and the feelings of fear and insecurity at anticipation of crime were not
considered in most documents reporting cost data on offending behaviour.
Consideration of these factors might increase the reported figures on cost-savings
resulting from reduction in offending behaviour achieved by offering Reasoning
and Rehabilitation programmes to adult offenders.
Rates of re-offending are higher in adults with more severe offending behaviour, as
expressed by the number of previous offences they committed in the past. Moreover,
this population commits a higher numbers of offences per year (Ministry of Justice,
2008a). Therefore, providing Reasoning and Rehabilitation to adults with more seri-
ous history of offending behaviour is likely to lead to higher cost savings from reduc-
tion in offending behaviour.
Reasoning and Rehabilitation programmes are intensive interventions and are
therefore characterised by high costs. It is possible that savings resulting from reduc-
tion in re-offending do not outweigh intervention costs. However, even if the inter-
vention resulted in a modest net cost per person, considering the further potential
benefits to participants and their families from implementation of the programme
(such as increase in employment rates, reduction in drug and alcohol misuse and other
healthcare costs), this cost may be justified.
The time horizon of the economic analysis was 1 year, as available evidence came
from relatively short-term studies, with a maximum time horizon of 9 months. There
is currently no evidence that Reasoning and Rehabilitation has a beneficial effect in
189
reducing offending behaviour extending beyond this time. Nevertheless, in order to

explore the potential magnitude of cost savings resulting from implementing the inter-
vention, the economic analysis considered multiple consecutive time periods of 1 and up
to 5 years to ascertain if the beneficial effect is retained in adult offenders. Further
research is needed to explore whether the effect of the intervention lasts in the long term,
as this would have substantial financial and emotional (positive) implications for society.
Conclusion
Group-based cognitive behavioural interventions delivered as Reasoning and
Rehabilitation programmes are potentially cost effective in the UK setting. Besides
the clinical benefits to adults with offending behaviour, they may produce net cost
savings to society, resulting from reduction in offending behaviour.
7.2.17 Evidence to recommendations
There is relatively robust clinical evidence indicating that cognitive and behavioural
interventions are moderately effective for offenders. The economic analysis showed
that such interventions are potentially cost saving, as the intervention costs may be
offset by savings associated with a reduction in re-offending; however, the results of
economic analysis were characterised by great uncertainty. The finding of a reduction
in re-offending is supported by evidence from cognitive and behavioural interventions
for offenders with substance misuse problems, which also have a significant impact
on reducing offending in a population with a high incidence of antisocial personality
disorder.
The GDG judged that it would be reasonable to conclude that such interventions
were likely to be effective for people with antisocial personality disorder. As was
noted in the Section 7.2.1, these interventions were developed and provided almost
exclusively within the criminal justice system. However, in addressing offending
behaviour the interventions also attempt to focus on problems with impulsivity,
aggression and rule-breaking. Such problems are also experienced by people with
antisocial personality disorder without criminal records. In light of this the GDG felt
it reasonable to extrapolate from this dataset of offenders and support the use of
group-based cognitive and behavioural interventions for non-offending populations
with antisocial personality disorder in the community.
In addition, the GDG considered that it would be possible to extrapolate these
findings to people who meet criteria for DSPD and therefore concluded that cogni-
tive and behavioural interventions would likely be moderately effective in this
population. However, it was also felt that the intervention would need to be adapted
in order to be beneficial for people with DSPD. The GDG also noted the recom-
mendation in the borderline personality disorder guideline (NICE, 2009) support-
ing use of multi-modal treatments, for example the combination of individual and
group treatments. Given that a proportion of people who meet criteria for DSPD
may have comorbid personality disorders, including borderline personality disor-
der, the GDG considered this recommendation when formulating recommendations
190
for antisocial personality disorder. Such modifications would include extending the
nature and duration of the intervention and providing close monitoring and super-
vision of staff.
7.2.18 Recommendations for offending behaviour in adults
7.2.18.1 For people with antisocial personality disorder, including those with
substance misuse problems, in community and mental health services,
consider offering group-based cognitive and behavioural interventions, in
order to address problems such as impulsivity, interpersonal difficulties
and antisocial behaviour.
7.2.18.2 For people with antisocial personality disorder with a history of offending
behaviour who are in community and institutional care, consider offering
group-based cognitive and behavioural interventions (for example,
programmes such as ‘Reasoning and Rehabilitation’) focused on reducing
offending and other antisocial behaviour.
7.2.18.3 When providing cognitive and behavioural interventions:
● assess the level of risk and adjust the duration and intensity of the
programme accordingly (participants at all levels of risk may benefit
from these interventions)
● provide support and encouragement to help participants to attend and
complete programmes, including people who are legally mandated to
do so.
7.2.18.4 For people in community and institutional settings who meet criteria for
psychopathy or DSPD, consider cognitive and behavioural interventions
(for example, programmes such as ‘Reasoning and Rehabilitation’)
focused on reducing offending and other antisocial behaviour. These inter-
ventions should be adapted for this group by extending the nature (for
example, concurrent individual and group sessions) and duration of the
intervention, and by providing booster sessions, continued follow-up and
close monitoring.
7.2.19 Clinical evidence for the treatment of offending behaviour

in young people
In addition to looking at adult offenders, the review also included young offenders up
to the age of 17 years. Eleven trials on cognitive behavioural interventions met the
inclusion criteria of the review where all but two trials were of interventions deliv-
ered in prison; OSTROM1971 and PULLLEN1996 were interventions delivered in
a probation setting. Eight trials were of cognitive and behavioural interventions
(GUERRA1990, LEEMAN1993, OSTROM1971, PULLEN1996, ROHDE2004,
SCHLICHTER1981, SHIVRATTAN1988, SPENCE1981) and three were multi-
component interventions (DEMBO2000, ELROD1992, GREENWOOD1993).
191
Summary study information and evidence from the included trials are shown in Table
39, Table 40 and Table 41. Full study characteristics and forest plots can be found in
Table 39: Study information table for trials of interventions targeted at

adolescents in the criminal justice system
Cognitive behavioural Multi-component

skills interventions intervention versus
versus control control
Total no. of trials 8 RCTs (N = 363) 3 RCTs (N = 426)
(total no. of
participants)
Study ID GUERRA1990 DEMBO2000
LEEMAN1993 ELROD1992
OSTROM1971 GREENWOOD1993
PULLEN1996
ROHDE2004
SCHLICHTER1981
SHIVRATTAN1988
SPENCE1981
Population Adolescents in the Adolescents in the criminal
criminal justice system justice system
Setting Institution: Institution and probation
GUERRA1990 (included after-care
LEEMAN1993 component):
SHIVRATTAN1988 GREENWOOD1993
SPENCE1981
Probation:
Probation: DEMBO2000
OSTROM1971 ELROD1992
PULLEN1996
Treatment length 74 days 175 days
Length of 6–15 months 12–24 months
follow-up
Age Range: 10–18 years Range: 11–18 years
Mean (3 studies report Mean (2 studies report
mean age): 16 years mean age): 16 years
192
Table 40: GRADE evidence summary for cognitive behavioural interventions

for adolescents in the criminal justice system
Population: Adolescents in the criminal justice system

Settings: Institution and probation
Intervention: Cognitive and behavioural interventions
Outcomes No. of Quality of Effect
participants the evidence estimates
(studies) (GRADE)
Re-offending [Completers] 269 丣丣 RR 0.65

(6) low1,2,3 (0.45 to 0.95)
Re-offending [ITT] 177 丣丣丣 RR 0.62

(4) moderate2 (0.39 to 0.98)
Bad outcome [continuous] 94 丣丣丣 SMD −0.11

(2) moderate2 (−0.52 to 0.3)
1 Completers analysis only
2 Wide confidence intervals
3 Not all outcomes are reported in results section
Table 41: GRADE evidence summary for multi-component interventions

versus control for adolescent offenders
Population: Adolescent offenders

Settings: Institution and/or probation
Intervention: Multi-component interventions
Outcomes No. of Quality of Relative effect
(studies) (GRADE)
Re-offending 426 丣丣 RR 0.87

(3) low1,2 (0.65 to 1.16)
1 Population is not directly antisocial personality disorder
2 No explanation was provided
193
The evidence suggests that cognitive behavioural interventions delivered prima-

rily in groups in institutional settings are more effective than control for reducing
offending for both intent to treat data (RR ⫽ 0.62; 0.39 to 0.98) and completer only
data (RR ⫽ 0.65, 0.45 to 0.95). All studies included only males, except for
GUERRA1990, which had both male and female participants.
Three trials on multi-component interventions for adolescent offenders were
included in the review. Two (DEMBO2000; ELROD1992) tested the efficacy of inter-
ventions delivered in the community and one (GREENWOOD1993) examined inter-
ventions provided in prison, which included an aftercare component in the
community. Multi-component interventions comprised family therapy, parenting
skills and cognitive problem-solving skills training (DEMBO2000); group-based
cognitive and behavioural interventions and parent training (ELROD1992); and
group-based cognitive and behavioural interventions and family therapy (GREEN-
WOOD1993). These studies found the intervention to have a modest but non-signif-
icant effect on re-offending (RR 0.87; 0.65 to 1.16). ELROD1992 and DEMBO2000
involved both male and female participants while GREENWOOD1993 included only
male participants. ELROD1992 was the least effective trial—in addition to group-
based cognitive and behavioural interventions and parent training, there was a wilder-
ness experience programme.
7.2.20 Clinical evidence summary for the treatment of offending

behaviour in young people
There appears to be modest but statistically significant evidence for the effectiveness
of group-based cognitive and behavioural interventions delivered in institutional
settings in reducing offending for adolescents involved in the criminal justice
system.
Multi-component interventions were less effective than the more focused
group-based cognitive and behavioural interventions. This is consistent with the
evidence found for multisystemic therapy. There is evidence from studies of
implementation of multisystemic therapy, and other complex multimodal interven-
tions, that maintaining fidelity to the model is strongly associated with a positive
outcome. It could be that the diminished effectiveness of the multi-component
interventions for offending behaviour reflected a lack of overall fidelity to or inte-
gration of the intervention.
7.2.21 Health economic evidence for the treatment of offending behaviour

in young people
Four US-based studies were identified in the systematic evidence search that
presented economic evaluations of interventions for young offenders (Caldwell et al.,
2006; Robertson et al., 2001; Myers et al., 2000; Dembo et al., 2000a). Details on the
194
characteristics and results reported in the studies are provided in the form of evidence
tables in Appendix 14. Details on the methods used for the systematic review of
the economic evidence are provided in Chapter 3.
Caldwell and colleagues (2006) compared an intensive juvenile corrective service
treatment programme with usual juvenile corrective service treatment in a secured
juvenile facility. The initial costs of the intensive programme were offset by improved
treatment progress and lowered violent recidivism. The intensive treatment
programme dominated usual treatment, resulting in lower net costs per offender and
better outcomes in terms of a reduction in felony and violent offences.
Robertson and colleagues (2001) performed a cost-benefit analysis, examining
local justice system expenditures associated with intensive supervision and monitor-
ing or CBT in comparison with regular probation. They demonstrated that, relative to
those on probation, the CBT programme resulted in a net saving in expenditure of
$1,435 per offender during the 18-month investigation. No significant difference in
justice system expenditures were demonstrated by the intensive supervision and
monitoring group.
The study by Myers and colleagues (2000) was a simple cost comparison study of
a multi-component intervention programme for early-career juvenile offenders. The
initial costs of the programme, total costs and differences in crime rates were
compared with respective costs and outcomes of an untreated community control
group. Over 12 months, the programme resulted in net savings of $1,800 per young
person due to lower crime rates compared with the untreated group.
Dembo and colleagues (2000a) compared the criminal justice costs of a family
empowerment intervention programme versus an extended services intervention
programme for juvenile offenders and their families. Over 2 years, the family empow-
erment intervention programme resulted in significant net savings mainly as a result
of lower arrest rates.
There was consistent evidence that cognitive and behavioural interventions were
effective for the treatment of offending behaviour in young people. In addition, these
interventions may be cost effective, according to evidence derived from US settings.
The use of such interventions for young people with offending behaviour is
supported.
7.2.23.1 For young offenders aged 17 years or younger with a history of offending
behaviour who are in institutional care, offer group-based cognitive and
behavioural interventions aimed at young offenders and that are focused
on reducing offending and other antisocial behaviour.
195
7.3 TREATMENT OF COMORBID DISORDERS IN PEOPLE WITH

7.3.1 Introduction
As highlighted in Chapter 2, people with antisocial personality disorder commonly

present with comorbid mental disorders including significant drug and alcohol prob-
lems, other personality disorders and a range of common mental health problems,
including depression and anxiety. The presence of these comorbidities will increase
the burden of illness and may directly contribute to the exacerbation of the problems
associated with the antisocial personality disorder. Unfortunately people with antiso-
cial personality disorder often reject treatment (Tyrer et al., 2003), and even where
they seek treatment for their comorbid disorders may find themselves unable to assess
treatment.
Current practice
The current treatment of comorbid mental health problems falls under three broad
categories: that provided by general mental health services in primary and secondary
care, that provided or funded by specialist mental health services in secondary and
tertiary care, and that provided within the criminal justice system.
The extent of treatment for comorbid disorders for common mental health prob-
lems such as anxiety and depression in primary and secondary mental health services
is not well known. It is likely, given what is known about the epidemiology of antiso-
cial personality disorder (for example, Robins et al., 1991; Swanson et al., 1994) that
a significant number of people do seek help but their comorbid problem may not be
recognised, or if they are offered treatment they may be more likely to drop out of it
or not adhere to it (ESMHCG, 2005). The position with regard to the treatment of
drug and alcohol problems is somewhat different, with a significant proportion of
people with drug or alcohol misuse disorders receiving treatment from specialist
substance misuse services provided by or funded by the NHS. This is important
because alcohol misuse is associated with increased violence in people with antiso-
cial personality disorder (Yang & Coid, 2007). An important issue is whether suffi-
cient adaptation of drug and alcohol treatment programmes is undertaken to engage
and retain people with antisocial personality disorder.
Within specialist mental health services, a small but growing number of units offer
treatment specifically for personality disorder (Crawford & Rutter, 2007). In princi-
ple these units have a remit to treat antisocial personality disorder (Department of
Health, 2003), but in practice few do (Crawford et al., 2007), with a much greater
focus on the treatment of borderline personality disorder.
Tertiary or forensic mental health services do treat people with antisocial person-
ality disorder and their associated comorbidities, but as noted in Chapter 4 the
percentage of people with antisocial personality disorder in the care of forensic serv-
ices is approximately 50% (Singleton et al., 1998).
Within the criminal justice system, there is considerable treatment of comorbid
mental disorders, primarily in prison settings, which comprises two aspects. First,
196
inmates’ general mental health is managed through prison-based mental health teams
(often linked to local mental health services). These services have seen significant
investment in recent years in recognition of the historically poor mental healthcare of
prisoners (ESMHCG, 2005), but it is likely that for many services the concentration
is on psychosis and other severe mental disorders. The second major area of activity
in addressing comorbid mental health problems in prison is the treatment of drug and
alcohol misuse, with many prisons now having specialist drug treatment services
(usually provided by the NHS or tertiary sector services).
Definition and aim of intervention

This review was limited to the following comorbid mental health problems:
a) drug and alcohol misuse in people with antisocial personality disorder
b) common mental disorders in people with antisocial personality disorder.
As there was limited evidence from individual trials or systematic reviews of
reasonable quality for other personality disorders in people with antisocial personal-
ity disorder, this review makes no further comment on this. The review acknowledges
that the presence of comorbid personality disorder in people with antisocial person-
ality disorder may have an overall consequence on treatment and would need to be
taken into consideration when formulating a treatment plan.
Psychotic disorders were excluded from the review in large part because where
antisocial personality disorder and a psychotic disorder co-exist, the primary focus of
treatment would be on the psychotic disorder.
Interventions were broadly defined to include all interventions for common
mental health disorders covered by the current NICE guidelines for those disorders
(for example, NCCMH, 2005a). For drug and alcohol misuse interventions NICE
guidelines were also used (NCCMH, 2007a, 2007b) along with other authoritative
guidance (for example, Department of Health, 2007b).
The review team conducted a new systematic search that assessed the efficacy of the
treatment of comorbid disorders for people with antisocial personality disorder.
Only one psychosocial trial reporting data relating to the treatment of comorbid
substance misuse in antisocial personality disorder met the eligibility criteria set by
the GDG, providing data on 108 participants with dependence on cocaine (Messina
et al., 2003). This trial compared contingency management, cognitive behavioural
therapy with one another and treatment as usual. In addition, there were four RCTs
that assessed in post hoc analyses the impact of antisocial personality disorder
197

Study design RCT, systematic review
Patient population People with antisocial personality disorder and comor-
bid disorders (including substance misuse, depression,
anxiety and other personality disorders)
People with personality disorder and comorbid disor-
ders (as above)
Interventions Psychological interventions
Outcomes Comorbid symptoms, offending
(compared with absence of an antisocial personality disorder diagnosis) on the

outcomes of psychosocial interventions. Two studies looked at these effects on partic-
ipants with drug misuse disorders (Woody, 1983; McKay et al., 2000) and a further
two trials on alcohol dependence (Wölwer et al., 2001; Hesselbrock, 1991). Five stud-
ies were excluded from the analysis. The most common reason for exclusion was
either treatment or control group did not have antisocial personality disorder.
7.3.4 Clinical evidence for psychological interventions for the treatment

of comorbid substance misuse
Messina and colleagues (2003) reported on a subgroup analysis of people with antisocial
personality disorder receiving either contingency management, CBT, a combination of
CBT and contingency management, or control. In addition, all participants were receiv-
ing methadone maintenance treatment. Contingency management was particularly effec-
tive for the treatment of drug misuse (RR 4.40; 1.20 to 16.17) in the antisocial personality
disorder population. These results were largely consistent with those found in a system-
atic review on psychosocial interventions for drug misuse (see NCCMH, 2007a).
Brooner and colleagues (1998) compared contingency management with control
in opioid dependent people with antisocial personality disorder. Contingency
management included contingent increases in methadone dose, scheduling of
methadone, therapy sessions that were more convenient for the participant, and so on.
There appeared to be a reduction in drug use for the treatment group compared with
control but this was not statistically significant. This study had a number of limita-
tions: first, urinalysis data were reported in a manner that could not rule out double
counting of individuals therefore it was difficult to interpret the results; second, this
study used a very different method of reinforcement (vouchers which could be
198
exchanged for goods and services) in comparison with Messina and colleagues
(2003), which may have contributed to the lack of positive effect.
Woody (1983) compared supportive-expressive psychotherapy with cognitive
behavioural psychotherapy for the treatment of opioid dependence. Woody reported
that participants with antisocial personality disorder had worse outcomes, whereas
participants with depression and no antisocial personality disorder generally showed
better outcomes. Participants with antisocial personality disorder and depression
generally fell in between the two groups on a broad range of drug misuse outcomes.
McKay and colleagues (2000) compared group therapy with individualised relapse
prevention for cocaine dependence and found no significant differences between
cocaine users with and without antisocial personality disorder for any substance
misuse outcome (including cocaine and alcohol).
Wölwer and colleagues (2001) compared CBT with coping skills training and
treatment as usual for alcohol dependence and found no significant differences
between subgroups of patients with or without antisocial personality disorder, as
measured by abstinence at 3 or 6 months after detoxification. In contrast, Hesselbrock
(1991) in a study of inpatient alcoholism treatment reported worse outcomes (as
measured by mean daily alcohol consumption and alcohol-related problems at 1 year)
for participants with antisocial personality disorder.
7.3.5 Clinical evidence summary for psychological interventions for the

treatment of comorbid substance misuse
The evidence on psychological interventions for drug misuse indicates that people
with antisocial personality disorder can benefit from treatment. There was a particu-
larly large effect found when using contingency management to treat drug misuse in
people with antisocial personality disorder. Although there was some inconsistency,
in that another trial did not show such positive effects, this appears to be partly
explained by the method of contingency management used in the latter trial and is
consistent with a review of the drug misuse literature that suggests that contingency
management has the strongest evidence for effectiveness (see NCCMH, 2007a,
2007b). While the other studies reviewed above do not report such positive effects,
the picture of generally poor outcomes for people with antisocial personality disor-
der, which is commonly assumed to be the case, was not confirmed. People with anti-
social personality disorder may be able to benefit as much from these interventions as
people without antisocial personality disorder.
7.3.6 Health economic evidence on the treatment of comorbid substance

misuse and alcohol dependence
No evidence on the cost effectiveness of treatments of comorbid substance misuse

and alcohol dependence was identified by the systematic search of the literature.
Details on the systematic search of the economic literature are provided in Chapter 3.
199
The limited evidence reviewed above suggests that people with antisocial personality
disorder can benefit from treatments for drug and alcohol misuse and that this bene-
fit could be of the same order as those without a personality disorder. The encourag-
ing results for contingency management are in line with the expectation that people
with antisocial personality disorder may respond well to positive reinforcement. It
was also the judgement of the GDG that such findings could generalise to people who
meet criteria for DSPD.
7.3.8.1 For people with antisocial personality disorder who misuse drugs, in
particular opioids or stimulants, offer psychological interventions (in
particular, contingency management programmes) in line with recommen-
dations in the relevant NICE clinical guideline [NICE, 2007].
7.3.8.2 For people with antisocial personality disorder who misuse or are depend-
ent on alcohol, offer psychological and pharmacological interventions in
line with existing national guidance for the treatment and management of
alcohol disorders.
7.3.8.3 For people who meet criteria for psychopathy or DSPD, offer treatment for
any comorbid disorders in line with existing NICE guidance. This should
happen regardless of whether the person is receiving treatment for
psychopathy or DSPD because effective treatment of comorbid disorders
may reduce the risk associated with psychopathy or DSPD.
7.3.9 The psychological treatment of comorbid depression and anxiety

disorders
There is considerable evidence that a personality disorder may have a negative impact
on the course of a common mental disorder (for example, Massion et al., 2002) and
that a common mental disorder may be associated with a poorer outcome in person-
ality disorder (for example, Yang & Coid, 2007). It is also the case that adults with
antisocial personality disorder often have multiple comorbidities. For example, those
with comorbid anxiety and antisocial personality disorder also had significantly
higher levels of comorbid depression, alcohol dependence and substance dependence
and higher rates of suicide attempts compared with adults with antisocial personality
disorder or anxiety disorders alone (Goodwin & Hamilton, 2003). This suggests that
effective treatment for common mental disorders in antisocial personality disorder
may be challenging but potentially important.
A systematic search identified no high-quality trials focused on the treatment of
depression or anxiety disorders comorbid with antisocial personality disorder.
Therefore the GDG and review team searched for high-quality systematic reviews that
200
addressed the question of the treatment of comorbid depression and anxiety disorders.
The GDG took the view that as the initial search for systematic reviews had failed to
identify a significant numbers of reviews focused solely on the issue of comorbidity
with antisocial personality disorder that they should consider (1) reviews of a broad
range of personality disorders and their impact on the treatment of depression and
anxiety and, (2) reviews of personality variables (such as trait anxiety, impulsivity and
aggression) that might have an impact on treatment outcomes. The GDG also agreed
to review the existing NICE guidelines for common mental disorders to determine if
any recommendations had been made about comorbid common mental health prob-
lems and antisocial personality disorder or indeed any other personality disorder.
A number of systematic reviews were identified and quality assessed. The follow-
ing reviews were considered (Dreessen & Arntz, 1998; Mulder et al., 2003; Newton-
Howes et al., 2006). In addition, the following NICE guidelines were also reviewed
(NCCMH, 2005a, 2005b, 2006, 2009a).
From these reviews a number of common themes emerged. First, there is no
consistent evidence that demonstrates people with antisocial personality disorder do
not benefit from evidence-based psychological interventions for common mental
health problems or that they may be harmed by such interventions (see for example
the reviews by Mulder and colleagues [2003] on personality disorder and depres-
sion). (It should be noted there is some evidence to suggest that brief interventions
may have little benefit for borderline personality disorder; NCCMH, 2009b.)
Second, there is evidence from post hoc analyses of individual trials that the pres-
ence of a personality disorder, or developmental or social factors that are commonly
associated with a personality disorder, may lead to a diminution of effectiveness.
This was commonly addressed in the treatment trials by extending the duration of
treatment (for example, Fournier et al., 2008). There was also some evidence that
more experienced therapists were better able to deal with Axis II comorbidity
(Hollon, personal communication, 2008). Nemeroff and colleagues (2003), in a post
hoc analysis of the Keller and colleagues’ (2000) trial of nefazodone and a cognitive
behavioural-analysis system of psychotherapy for chronic depression, found that
patients with a significant history of childhood trauma obtained better outcomes with
psychological treatment, while those with no history of abuse obtained better
outcomes with pharmacological treatments.
7.3.10 Clinical evidence summary for the psychological treatment of

comorbid depression and auxiety disorders
People with antisocial personality disorder have high levels of comorbid common
mental health problems, which are associated with poorer long-term outcomes.
Evidence from clinical trials relating directly to this issue is lacking, but post hoc
analysis of data drawn from individual trials and from systematic reviews across a
range of personality disorders suggest that effective treatment of common mental
health disorders is possible, but may require the extension of the duration of the treat-
ment and/or high levels of clinical skill and experience.
201
7.3.11 Health economic evidence on the treatment of comorbid depression

and anxiety disorders
No evidence on the cost effectiveness of treatments of comorbid depression and anxi-

ety disorders was identified by the systematic search of the literature. Details on the
methods adopted in the systematic search of the economic literature are provided in
Chapter 3.
The evidence reviewed suggested that the treatment of common mental disorders in
antisocial personality disorder is possible, but that caution is required in developing
any recommendations because the evidence base is drawn from trials involving a
wider range of personality disorders than just antisocial personality disorder. There is
a clear indication in the evidence reviewed that consideration should be given to
extending the duration of treatment. In addition, staff should be mindful of the need
to take steps to address the increased likelihood that people with antisocial personal-
ity disorder will drop out of treatment.
7.3.13.1 People with antisocial personality disorder should be offered treatment for
any comorbid disorders in line with recommendations in the relevant
NICE clinical guideline, where available. This should happen regardless
of whether the person is receiving treatment for antisocial personality
disorder.
7.3.13.2 When providing psychological interventions for comorbid disorders to
people with antisocial personality disorder, consider lengthening their
duration or increasing their intensity.
7.4 THERAPEUTIC COMMUNITY INTERVENTIONS FOR

PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER
AND ASSOCIATED SYMPTOMS AND BEHAVIOURS
7.4.1 Introduction
In the history of psychological treatments for personality disorder the therapeutic

community has played an important role (Rapoport, 1960). The therapeutic commu-
nity movement had a significant impact on mental healthcare in the mid to late 20th
century (Lees et al., 2003) with developments in the prison service (Snell, 1962), drug
services and for other personality disorders (Lees et al., 2003). However, in healthcare
202
there has been a recent move away from therapeutic communities, in part influenced
by high costs in the absence of convincing evidence for efficacy (Lees et al., 2003).
Therapeutic communities differ from other treatment approaches in the use of the
residential ‘community’ as the key agent for change. Peer influence is used to help
individuals acquire social skills and learn social norms, and so take on an increased
level of personal and social responsibility within the unit (Smith et al., 2006). In addi-
tion to therapeutic communities based on social learning theory, there are rehabilita-
tion centres that emphasise more behavioural, hierarchical principles that positively
and negatively reinforce a range of behaviours. Residential therapeutic communities
involve therapeutic group work, one-to-one keyworking, the development of practical
skills and interests, education and training. The intensive nature of their approach
means that such programmes tend to be longer in duration (6 to 12 months)
(Greenwood et al., 2001). In the UK, the Community of Communities project
(Keenan & Paget, 2006) has developed standards of good practice for therapeutic
communities.
Current practice
Therapeutic communities are found within health, education and social care and
prison settings in the UK and often work with people with symptoms and behaviours
associated with the antisocial personality disorder construct.
There are a number of therapeutic communities specialising in the treatment of
substance misuse, with over half of residential services in the National Treatment
Agency for Substance Misuse online directory12 describing themselves as therapeu-
tic communities. In addition, of the 56 therapeutic communities surveyed by the
Community of Communities, 15 were in prison settings (Royal College of
Psychiatrists, 2008b).
The review assessed therapeutic communities for people with antisocial personality
disorder, people with symptoms and behaviours associated with this diagnostic
construct, and people with comorbid substance misuse.
12See http://www.nta.nhs.uk/about_treatment/treatment_directories/residential/resdirectory_f.aspx
203


Study design RCT, non-RCT
Patient population People with antisocial personality disorder, people
with symptoms and behaviours associated with antiso-
cial personality disorder
Interventions Therapeutic communities
Outcomes Offending
The review team conducted a new systematic search for RCTs that assessed the effi-
cacy of therapeutic communities for people with antisocial personality disorder or
symptoms and behaviours associated with antisocial personality disorder. A system-
atic search for non-RCTs that assessed the efficacy of therapeutic communities for
offenders was also conducted.
There were no trials of therapeutic communities for people with antisocial person-
ality disorder that met the eligibility criteria of the GDG. However, three trials that
assessed therapeutic communities for offenders who misused drugs (NIELSEN1996;
SACKS2004; WEXLER1999) met the eligibility criteria set by the GDG, providing
data on 1,682 participants. All were published in peer-reviewed journals.
As there was only one RCT for therapeutic communities for offenders without
substance misuse problems (Lamb & Goentzel, 1974), the review team conducted a
systematic search for non-RCTs that assessed the efficacy of therapeutic communi-
ties in this population; two non-RCTs (Marshall, 1997; Robertson & Gunn, 1987)
were identified.
In addition, seven studies were excluded from the analysis. The most common
reason for exclusion was the lack of relevant outcomes (further information about
both included and excluded studies can be found in Appendix 15).
13Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capi-
204
7.4.5 Clinical evidence on therapeutic communities for offenders with

substance misuse problems
Three RCTs have been conducted in institutional settings evaluating the evidence for
therapeutic communities in substance misuse offenders. In two trials the intervention
included treatment within prison followed by release to a residential community of 6
months’ duration (SACKS2004; WEXLER1999). The third trial (NIELSEN1996)
assessed a work-release therapeutic community programme.
Summary study information and evidence from the included trials are shown in
Table 44 and Table 45. Full evidence profiles and forest plots can be found in
Appendices 15 and 16.
Therapeutic community prison and aftercare programmes for offenders who
misused drugs (many of whom had antisocial personality disorder) were associated
with relatively large reductions in offending (RR ⫽ 0.62; 0.49 to 0.78). At 5-year
follow-up the difference was still statistically significant (RR ⫽ 0.93; 0.87 to 0.99).
Table 44: Study information table for trials of therapeutic communities for
offenders with substance misuse problems
Therapeutic community + aftercare versus control

for substance misuse offenders
Total no. of trials 3 RCTs (N ⫽ 1682)

(total no. of
participants)
Study ID NIELSEN1996
SACKS2004
WEXLER1999
Diagnosis Psychiatric: 70% Axis I, 39% antisocial personality
disorder (SACKS2004), 51.5% antisocial personality
disorder (WEXLER2004)
Drug: 100% illicit drug use

(NIELSEN1996, SACKS2004, WEXLER2004)
Treatment length 1 year prison therapeutic community and 1 year
community-based aftercare: WEXLER1999
6 months’ prison therapeutic community

NIELSEN1996
1 year prison therapeutic community and 6 months⬘
community-based aftercare: WEXLER2004
Length of follow-up 1 to 5 years
205
Table 45: GRADE evidence summary for therapeutic communities for

offenders with substance misuse problems
Population: Antisocial personality disorder

Settings: Criminal justice system
Intervention: Prison therapeutic community
Comparison: Prison control
(studies) (GRADE)
Offending (12-month 1682 丣丣丣 RR 0.62

follow up) (3) moderate1 (0.49 to 0.78)
1 I-squared ⬎50%
7.4.6 Health economic evidence on therapeutic communities for offenders

with substance misuse problems
Four US-based studies that reported on the cost-effectiveness of therapeutic commu-

nities for offenders with substance abuse problems were identified by the systematic
search of economic literature (McCollister et al., 2003, 2003a and 2004; Griffith
et al., 1999). One study by McCollister and colleagues (2003, 2004) evaluated the
short and long-term cost-effectiveness (12 months and 5 years respectively) of a
Californian in-prison therapeutic community and aftercare programme for male pris-
oners with history of substance misuse. Cost data included in-prison and aftercare
treatments, hospital inpatient and outpatient episodes, methadone treatments and
other self-help programmes. The measure of effectiveness was the number of incar-
ceration days avoided during follow-up. In the comparison with no treatment, the
ICER was $80 per avoided incarceration day after 12 months, which came down to
$65 after 5 years. A similar study based in Delaware evaluated a work-release thera-
peutic community and aftercare programme for male prisoners with history of
substance misuse (McCollister et al., 2003a). Only costs of the in-prison and after-
care treatment programmes were included and follow-up was 18 months. The ICER
versus no treatment was $65 per incarceration day avoided.
Another study evaluated the cost effectiveness of in-prison therapeutic community
treatment for male offenders with a history of substance misuse in Texas (Griffith
et al., 1999). A retrospective analysis was undertaken over 3 years, comparing treated
offenders’ parole and aftercare costs, as well as re-incarceration rates, with respective
costs and outcomes in an untreated comparison group. Separate analyses were
conducted for low-risk and high-risk offenders. For the low-risk group analysis, the
ICER was $494 per 1% reduction in re-incarceration; for the high-risk group analy-
sis, the ICER fell to $165. This was largely explained by the higher re-incarceration
206
rates experienced by the high-risk untreated group compared with the treated group,
while for the low-risk group analysis, re-incarceration rates were similar in the two
cohorts (treated and untreated).
Details on the study characteristics and results are provided in the form of
evidence tables in Appendix 14. The methods adopted for the systematic review of
economic literature are discussed in Chapter 3.
7.4.7 Clinical evidence on therapeutic communities for adult offenders
There were three trials that investigated the efficacy of therapeutic communities for
general offenders in institutional and community settings. Of these, one was an RCT
(Lamb & Goentzel, 1974) and two were non-RCTs (Marshall, 1997; Robertson & Gunn,
1987). The RCT investigated a community alternative to prison in the US and the two
non-RCTs investigated the effects of therapeutic communities for prisoners treated in
HMP Grendon in the UK. For general offenders a meta-analysis was not conducted as
these studies differed in study design; instead these studies were narratively reviewed.
Lamb & Goentzel (1974) randomised participants to regular prison services or to
a therapeutic community as an alternative to prison in a community setting. The ther-
apeutic community comprised three phrases. In phases one and two, the participants
were given more responsibility and privileges within each phase. Phase three contin-
ued while the participant was on probation. The participant returned to the therapeu-
tic community to visit their assigned probation officer and to participate in social
activities. The study found the therapeutic community to have a harmful effect on re-
offending at 1-year follow-up for 31 participants in the treatment group in compari-
son with 31 participants in the control group (RR 1.22; 0.59, 2.53).
Robertson & Gunn (1987) conducted a 10-year prospective cohort study of partic-
ipants released from HMP Grendon in comparison with a matched control; there were
some differences between the two groups, such as the treated group having more desire
for psychiatric help compared with the control group. The study found no significant
differences between participants treated in a therapeutic community compared with
regular prison services (93% and 85% respectively, x2 ⫽ 1.37, d.f. 1, NS).
Marshall (1997) conducted a retrospective cohort study of participants who stayed
in HMP Grendon (N ⫽ 702) from 1984 to 1989. These participants were compared
with participants who were selected for Grendon in the same period but who did not
actually go there (N ⫽ 142). The retrospective study found no effect on the therapeu-
tic community for participants who attended Grendon versus the comparison group
who did not (RR 0.92; 0.82 ⫺1.03).
7.4.8 Health economic evidence on therapeutic communities for

adult offenders
No economic evidence on therapeutic communities for adult offenders was identified

in the literature.
207
7.4.9 Clinical evidence summary on therapeutic communities
The majority of RCT evidence available on therapeutic communities was on people

who misuse drugs in the criminal justice system. These samples had a fair proportion
of people diagnosed with antisocial personality disorder (between 39 and 51%) in
addition to all participants reporting behaviour or symptoms associated with the anti-
social personality disorder diagnostic construct. There was found to be a relatively
large reduction in offending. The economic evidence suggests that in-prison therapeu-
tic communities for offenders with history of substance abuse may be cost effective
in terms of reducing future re-offending.
In contrast the evidence for therapeutic communities for general offenders is
limited and based on weaker study design. There is no evidence to suggest that ther-
apeutic communities are effective for general offenders.
The GDG concluded that therapeutic communities appeared to be effective for people
in prison or on probation who misuse drugs, many of whom were diagnosed with
antisocial personality disorder. Therefore their judgement was that therapeutic
communities targeted specifically at drug misuse are likely to be effective in people
with antisocial personality disorder who misuse drugs. However, the GDG concluded
there was insufficient evidence to apply these findings to therapeutic communities
targeting general offenders.
7.4.11.1 For people with antisocial personality disorder who are in institutional care
and who misuse or are dependent on drugs or alcohol, consider referral to
a specialist therapeutic community focused on the treatment of drug and
alcohol problems.
7.5 PHARMACOLOGICAL INTERVENTIONS FOR ANTISOCIAL

7.5.1 Introduction
A rationale for pharmacological approaches in antisocial personality disorder is that

many of the behavioural traits of personality disorder may have a biological basis
and are associated with neurochemical abnormalities of the central nervous system
(Coccaro et al., 1996a, 1996b; Hollander et al., 1994). However, a major problem in
studying the effects of medication is that it is difficult to map drug action on the
personality disorders as they are listed in DSM. The reason for this is that they are
208
so heterogeneous that it may be more fruitful to focus on behavioural clusters

(Markovitz, 2001). Soloff (1998) has been influential by introducing a symptom-
orientated approach. Ignoring the specific DSM Axis II disorders, he grouped
personality psychopathology into the following symptom domains: cognitive-
perceptual, affective, impulse-behavioural and anxious-fearful. Affective symptoms
in turn were subdivided into dysregulation of (a) mood and (b) anxiety. He suggested
that since these domains were mediated by the same neurotransmitter systems as
Axis I disorders, albeit in an attenuated form, this approach could lead to more
rational prescribing.
Applying this approach, Soloff found evidence that conventional antipsychotic
drugs in low doses were effective in reducing the cognitive perceptual abnormalities
(Soloff et al., 1986a; Goldberg et al., 1986). For dysregulation of mood, there was some
evidence for the use of SSRIs (Cornelius et al., 1990; Markovitz et al., 1991), tricyclic
antidepressants (Soloff et al., 1986b), venlafaxine (Markovitz & Wagner, 1995) and
monoamine oxidase inhibitors (MAOIs) (Parsons et al., 1989). For impulsive behav-
ioural dyscontrol, most attention had been focused on the SSRIs (Cornelius et al., 1990;
Kavouissi et al., 1994), but lithium (Tupin et al., 1973; Links, 1990) and anticonvulsants
such as carbamazepine (Cowdry & Gardner, 1989), valproate (Stein et al., 1995) and
divalproex sodium (Wilcox, 1995) had also shown some positive outcomes.
Various features of antisocial personality disorder might be targets for a pharma-
cological intervention. Paranoia, for instance, emerges from factor analysis and
hence might be a target of low-dose antipsychotic medication. Similarly, impulsive
dyscontrol and aggressive behaviour are important features of antisocial personality
disorder and might usefully be targeted with SSRIs or mood stabilisers. This section
therefore reviews the evidence on the use of drugs for those with antisocial person-
ality disorder.
As with assessing the effectiveness of psychological interventions, there are three
difficulties that need to be considered. First, antisocial personality disorder is often
comorbid with Axis I conditions and, as it may often be the presence of the latter that
causes the individual to present for treatment, it is not always clear whether it is the
Axis I or Axis II condition that is being targeted when medication is used. Second,
use of alcohol and other illicit substances, which is common in people with antiso-
cial personality disorder, may diminish response rates to pharmacotherapy
(Markovitz, 2001). Third, with complex conditions such as antisocial personality
disorder, it is likely that multiple neurotransmitter systems are at play in producing,
for example, the affective dysregulation (Soloff, 1998). This again makes drug selec-
tion difficult.
Current practice
The state of current practice in relation to the use of pharmacological interventions to
treat antisocial personality disorder is unclear, but it is likely that pharmacological inter-
ventions are used in this population to treat symptoms rather than as an intervention for
the disorder itself. The reported level of prescription in the prison population does not
suggest that pharmacological interventions are used at a generally high level in offender
populations (Christina Rowlands, presentation to the GDG, December 2007).
209
Ten trials relating to clinical evidence met the eligibility criteria set by the GDG,
providing data on 749 participants (BARRATT1997, COCCARO1997A,
GOTTSCHALK1973, HOLLANDER2003, LEAL1994, MATTES2005, MATTES-
2008, NICKEL2005B, POWELL1995, SHEARD1976, STANFORD2005). Of these,
all were published in peer-reviewed journals between 1973 and 2008. In addition, 16
studies were excluded from the analysis. The most common reasons for exclusion
were non-random allocation of participants to treatment and control and populations
that would not meet the GDG’s inclusion criteria, for example, participants with
schizophrenia (further information about both included and excluded studies can be
found in Appendix 15).
There was one trial providing evidence for pharmacological interventions for anti-
social personality disorder (BARRATT 1997). The purpose of the study was to look
at the effects of anticonvulsants on aggression among offenders in prison, however all
participants at baseline met DSM-III-R criteria for antisocial personality disorder.

Study design RCT
Patient population People with antisocial personality disorder; people
with antisocial personality disorder and comorbid
disorders; people with symptoms and behaviours asso-
ciated with antisocial personality disorder
Interventions Pharmacological interventions
Outcomes Reduction in symptoms or behaviours associated with
the antisocial personality disorder construct
14Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in
captial letters (primary author and date of study population, except where a study is in press or only submit-
210
Two trials were found that investigated pharmacological interventions for a sub-
population of antisocial personality disorder with comorbid substance misuse.
(LEAL1994, POWELL1995) One trial compared amantadine and desipramine with
placebo for participants with cocaine dependence (LEAL1994) and one trial compared
nortriptyline and bromocroptine with placebo for participants with alcohol dependence
(POWELL1995).
For the review of pharmacological evidence for antisocial personality disorder and
associated symptoms or behaviour, eight trials were included (COCCARO1997A,
GOTTSCHALK1973, HOLLANDER2003, MATTES2005, MATTES2008,
NICKEL2005, SHEARD1976, STANFORD2005). Six trials compared anticonvul-
sants with placebo (GOTTSCHALK1973, HOLLANDER2003, MATTES2005,
MATTES2008, NICKEL2005, STANFORD2005), one compared antidepressants
with placebo (COCCARO1997A) and one compared lithium with placebo
(SHEARD1976). The population in all the trials had an elevated level of impulsive
aggression and/or anger while two trials looked specifically at offenders
(SHEARD1976, GOTTSHALK1993). The age range for the trials were 19 to 67 years.
7.5.4 Clinical evidence for antisocial personality disorder
There was one trial (see Table 47 and Table 48) that looked at the effects of anticon-
vulsants on aggression among prison inmates who all met DSM-III-R criteria for anti-
social personality disorder (BARRATT1997). Using the modification of the Overt
Aggression Scale (OAS), the study found the anticonvulsant phenytoin to have a
small but non-significant effect on aggression compared with placebo (SMD ⫺0.26;
⫺0.61, 0.09). Full study characteristics and forest plots can be found in Appendices
15 and 16 respectively.
Table 47: Study information on pharmacological interventions for antisocial

Anticonvulsant versus placebo

Total no. of trials (total no. 1 RCT (N = 126)
of participants)
Study ID BARRATT1997
Diagnosis Antisocial personality disorder
Setting Prison
Treatment length Mean: 42 days
Length of follow-up Not relevant
Age Not reported
211
Table 48: GRADE evidence summary table on pharmacological interventions

for antisocial personality disorder
Population: Antisocial personality disorder

Settings: Prison
Intervention: Anticonvulsants
Comparison: Placebo
(studies) (GRADE)
OAS-M (aggression 126 丣丣 SMD −0.26

intensity) change score (1) low1,2 (−0.61 to 0.09)
1 Only one trial
2 Confidence intervals cross the line of no effect
7.5.5 Clinical evidence for antisocial personality disorder and comorbid

substance misuse
Two trials (LEAL1994, POWELL1995) studied the effects of antidepressants in

people with antisocial personality disorder and comorbid substance misuse compared
with placebo (see Table 49). It was not possible to meta-analyse the data so there is
no GRADE evidence summary table. Summary study information and evidence from
the included trials are shown in Table 43 and Table 44. Full study characteristics can
be found in Appendix 15.
For antidepressants versus placebo there was a small effect for leaving the study
early (RR 0.90; 0.52, 1.55) for participants with cocaine dependence (LEAL1994)
and alcohol dependence (POWELL1995), and a moderate effect on abstinence (RR
0.72; 0.53–0.97) for participants with alcohol dependence. However, the effect on
abstinence was small and based on only one study (POWELL1995).
The two trials also looked at the effects of dopaminergic drugs versus placebo
(LEAL1994, POWELL1995). No significant differences were found between drop
out for both treatment and placebo groups (RR 1.18; 0.72, 1.94) and a small but non-
significant difference was found in abstinence for participants with alcohol depend-
ence (RR 0.91; 0.75, 1.10). This effect was small and based on sparse data.
7.5.6 Clinical evidence for antisocial personality disorder and associated

symptoms or behaviour
Table 50 summarises the study information for trials concerned with pharmacologi-
cal interventions for aggression in people with antisocial personality disorder. The
GRADE evidence summaries can be found in Table 51.
212
Table 49: Study information for pharmacological interventions for antisocial

personality disorder with comorbid substance misuse
Antidepressants versus Dopaminergic versus

placebo placebo
Total no. of trials 2 RCTs (N = 83) 2 RCTs (N = 83)
(total no. of
participants)
Study ID LEAL1994 LEAL1994
POWELL1995 POWELL1995
Diagnosis Cocaine dependence: Cocaine dependence:
LEAL1994 LEAL1994
Alcohol dependence: Alcohol dependence:
Setting Outpatient: Outpatient:
LEAL1994 LEAL1994
Inpatient and outpatient: Inpatient and outpatient:
Treatment length Mean: 135 days Mean: 135 days
Length of follow-up Not relevant Not relevant
Age Mean: 36.5 years Mean: 36.5 years
Full study characteristics and forest plots can be found in Appendices 15 and 16
respectively.
Anticonvulsants versus placebo

Six trials investigated the effects of a number of anticonvulsants on impulsive aggres-
sion and found a small and non-significant effect on aggression at end of treatment
(SMD ⫺0.13; ⫺0.35 to 0.09). The quality of evidence was very low with high hetero-
geneity (I2 ⫽ 74.4%).
SSRIs versus placebo

One trial compared the SSRI fluoxetine with placebo for reducing aggression in a popu-
lation with elevated aggression and found the effects of treatment to be medium to large
(SMD ⫺0.73; ⫺1.41 to ⫺0.04). However, this is based on one study of low quality.
Lithium versus placebo

There was only one trial that investigated lithium versus placebo in a population with
elevated levels of the antisocial personality disorder construct aggression that met the
213
Table 50: Study information for the trials of pharmacological interventions

for aggression
Anticonvulsants versus Antidepressants versus Lithium versus

placebo placebo placebo
Total no. of trials 6 RCTS (N ⫽ 433) 1 RCT (N ⫽ 40) 1 RCT (N ⫽ 66)

(total no. of
participants)
Study ID GOTTSCHALK1973 COCCARO1997A SHEARD1976
HOLLANDER2003
MATTES2005
MATTES2008
NICKEL2005B
STANFORD2005
Diagnosis Offenders: Personality disorder and Offenders
GOTTSCHALK1973 antisocial personality
disorder construct –
Antisocial personality impulsive aggressive
disorder construct -
impulsive aggressive:
HOLLANDER2003
MATTES2005
MATTES2008
Antisocial personality
disorder construct -
anger problems:
NICKEL2005B
Setting Institution (Prison): Outpatient Institution (prison)
GOTTSCHALK1973
Outpatient:
HOLLANDER2003
MATTES2005
MATTES2008
NICKEL2005B
STANFORD2005
Average treatment 83 days 84 days 90 days
length
Length of follow-up None None None
Age Range: 19–67 years Mean: 38 years Mean: 66 years
214
Table 51: GRADE evidence summary for pharmacological interventions

for aggression
Anticonvulsants versus placebo for aggression
Patient or population: Antisocial personality disorder diagnostic construct – aggression

Intervention: Anticonvulsant
Comparison: Placebo
Outcomes No. of participants Quality of the Comments

(studies) evidence (GRADE)
Aggression (end of 332 丣 SMD −0.13

treatment) (4) very low1,2,3 (−0.35 to 0.09)
Leaving the study early 354 丣 RR 3.94

due to adverse events (4) very low1,2,3 (1.92 to 8.11)
Aggression change score 84 丣丣 SMD −0.13

(end of treatment) (2) low1,2 (−0.56 to 0.3)
1 I squared ⬎50%
2 Population does not include antisocial personality disorder
3 Wide confidence intervals
SSRI antidepressants versus placebo for aggression

Intervention: SSRI antidepressant
Comparison: Placebo

Aggression (end of 40 丣 SMD −0.73

treatment) (1) very low1,2 (−1.41 to −0.04)
Leaving the study early 40 丣丣 RR 1.53

due to adverse events (1) low1,2 (0.06 to 40.09)
1 10% of population has antisocial personality disorder
2 Few participants
Lithium versus placebo for aggression

Intervention: Lithium
Comparison: Placebo
Outcomes No. of participants Quality of the Comments

Aggression (end of 41 丣丣 SMD −0.6

treatment) (1) low1 (−1.23 to 0.03)
Leaving the study early 66 丣丣 RR 1.2

(1) low1,2 (0.64 to 2.24)
1 Population does not include antisocial personality disorder
2 Few participants resulting in wide confidence intervals
215
eligibility criteria. The trial showed a medium effect for treatment, which was,
however, non-significant and of low quality (SMD ⫺0.60; ⫺1.23, 0.03).
7.5.7 Clinical evidence summary for antisocial personality disorder and

associated symptoms or behaviour
There was no consistent evidence, including from uncontrolled studies, that

supported the use of any pharmacological intervention to treat antisocial personality
disorder or to treat the behaviour and symptoms that underline the specific diagnos-
tic criteria for antisocial personality disorder.
7.5.8 Health economic evidence on pharmacological interventions for

No evidence on the cost effectiveness of pharmacological interventions for antisocial

personality disorder with or without comorbid substance misuse and associated
symptoms of behaviour was identified by the systematic search of the literature.
Details on the methods adopted for the systematic review of economic literature are
provided in Chapter 3.
The evidence did not support the generation of recommendations for the routine use
of pharmacological interventions for the treatment of people with antisocial person-
ality disorder.
7.5.10 Recommendations for pharmacological interventions
7.5.10.1 Pharmacological interventions should not be routinely used for the treat-
ment of antisocial personality disorder or associated behaviours of aggres-
sion, anger and impulsivity.
7.5.10.2 Pharmacological interventions for comorbid mental disorders, in particular
depression and anxiety, should be in line with recommendations in the
relevant NICE clinical guideline. When starting and reviewing medication
for comorbid mental disorders, pay particular attention to issues of adher-
ence and the risks of misuse or overdose.
7.5.11 Recommendations on general issues in the treatment of adults with

7.5.11.1 When providing psychological or pharmacological interventions for anti-

social personality disorder, offending behaviour or comorbid disorders to
216
people with antisocial personality disorder, be aware of the potential for

and possible impact of:
● poor concordance
● high attrition
● misuse of prescribed medication
● drug interactions (including with alcohol and illicit drugs).
7.6 RESEARCH RECOMMENDATIONS
Through identifying research limitations from the evidence based reviews, the guide-
line development group has formulated the following research recommendations.
7.6.1.1 Severity as a potential moderator of effect in group-based cognitive

and behavioural interventions
Does the pre-treatment level of the severity of disorder/problem have an impact on
the outcome of group-based cognitive and behavioural interventions for offending
behaviour? A meta-analysis of individual participant data should be conducted to
determine whether the level of severity assessed at the beginning of the interven-
tion moderates the effect of the intervention. The study (for which there are large
data sets that include over 10,000 participants) could inform the design of a large-
scale RCT (including potential modifications of cognitive and behavioural inter-
ventions) to test the impact of severity on the outcome of cognitive and
behavioural interventions.

Research has established the efficacy of cognitive and behavioural interventions in
reducing re-offending. However, the effects of these interventions in a range of
offending populations are modest. The impact of severity on the outcome of these
interventions has not been systematically investigated, and post hoc analyses and
meta-regression of risk as a moderating factor have been inconclusive. Expert opin-
ion suggests that severe or high-risk individuals may not benefit from cognitive and
behavioural interventions, but if they were to be of benefit then the cost savings could
be considerable.
7.6.1.2 Group-based cognitive and behavioural interventions for populations

outside criminal justice settings
Are group-based cognitive and behavioural interventions effective in reducing the
behaviours associated with antisocial personality disorder (such as impulsivity, rule-
breaking, deceitfulness, irritability, aggressiveness and disregard for the safety of self
or others)? This should be tested in an RCT that examines medium-term outcomes
(including cost effectiveness) over a period of at least 18 months. It should pay partic-
ular attention to the modification and development of the interventions to ensure the
focus is not just on offending behaviour, but on all aspects of the challenging behav-
iours associated with antisocial personality disorder.
217

Not all people with antisocial personality disorder are offenders but they exhibit a
wide range of antisocial behaviours. However, the evidence for the treatment of these
behaviours outside the criminal justice system is extremely limited. Following publi-
cation of the Department of Health’s policy guidance, Personality Disorder: No
Longer a Diagnosis of Exclusion (2003), it is likely that there will be an increased
requirement in the NHS to offer treatments for antisocial personality disorder.
7.6.1.3 Treatment of comorbid anxiety disorders in antisocial personality

disorder
Does the effective treatment of anxiety disorders in antisocial personality disorder
improve the long-term outcome for antisocial personality disorder? An RCT of
people with antisocial personality disorder and comorbid anxiety disorders that
compares a sequenced treatment programme for the anxiety disorder with usual care
should be conducted. It should examine, over a period of at least 18 months, the
medium-term outcomes for key symptoms and behaviours associated with antisocial
personality disorder (including offending behaviour, deceitfulness, irritability and
aggressiveness, and disregard for the safety of self or others), as well as drug and
alcohol misuse, and anxiety. The study should also be designed to explore the moder-
ators and mediators of treatment effect which could help determine the role of anxi-
ety in the course of antisocial personality disorder.

Comorbidity with Axis I disorders is common in antisocial personality disorder, and
chronic anxiety has been identified as a particular disorder that may exacerbate the
problems associated with antisocial personality disorder. There are effective treat-
ments (psychological and pharmacological) for anxiety disorders but they are often
not offered to people with antisocial personality disorder. Current treatment guide-
lines set out clear pathways for the stepped or sequenced care of people with anxiety
disorders. An RCT to test the benefit of this approach in the treatment of anxiety
would potentially lead to a significant reduction in illness burden but a reduction in
antisocial behaviour would have wider societal benefits. The study should provide
important information on the challenges of delivering these interventions for a popu-
lation that has typically both rejected and been refused treatment.
7.6.1.4 Using selective serotonin reuptake inhibitors to increase cooperative

behaviour in people with antisocial personality disorder in a prison
setting
Although there is evidence that selective serotonin reuptake inhibitors (SSRIs), such
as paroxetine, increase cooperative behaviour in normal people and do so independ-
ently of the level of sub-syndromal depression, this has yet to be tested in other
settings. Given that people with antisocial personality disorder are likely to have diffi-
culties cooperating with one another (because of a host of personality traits that
include persistent rule-breaking for personal advantage, suspiciousness, grandiosity,
218
and so on), an RCT should be conducted to find out whether these reported changes
of behaviour with an SSRI in normal people generalises to clinical populations in
different settings.

There is little evidence in the literature on the pharmacotherapy of antisocial person-
ality disorder to justify the use of any particular medication. However, multiple drugs
in various combinations are used in this group either to control aberrant behaviour or
in the hope that something might work. Current interventions lack a clear rationale.
This recommendation has the potential to advance the field in that (a) it is linked to a
clear hypothesis (that cooperative behaviour is linked to a dysregulation of the sero-
tonin receptors – for which there is substantial evidence) and (b) that it is feasible to
obtain an answer to this question, given that there are a large number of individuals
detained in prison settings who would meet antisocial personality disorder criteria.
Constructing an experimental task that requires cooperative activity would not be
difficult in such a setting, since all of those who might be willing to participate are
already detained. The successful execution of this research would be important in that
it (a) would establish the feasibility of conducting such a trial in a prison setting with
this group, and (b) provide a clear and sensible outcome measure of antisocial behav-
iour that might be generalised to other settings.
7.6.1.5 A therapeutic community approach for antisocial personality disorder

in a prison setting
Is a therapeutic community approach in a prison setting more clinically and cost effec-
tive in the treatment and management of antisocial personality disorder than routine
prison care? There should be a large-scale RCT comparing the clinical and cost effec-
tiveness of the therapeutic community approach for adults with antisocial personality
disorder with routine care. It should examine the medium-term outcomes (for example,
offending behaviour, mental state and vocational outcomes) over a period of at least
18 months following release from prison. The study should also be designed to explore
the moderators and mediators of treatment effect, which could help to determine the
factors associated with benefits or harms of the therapeutic community approach.

There is evidence from RCTs that the therapeutic community approach is of value
with drug and alcohol misusers in a prison setting at reducing the incidence of offend-
ing behaviour on release. However, there are no equivalent studies of a programme in
the prison system on antisocial personality disorder populations that do not have
significant drug or alcohol problems. Data that do exist are from non-UK settings.
Answering this question is of importance because outcomes for adults with antisocial
personality disorder are poor and there are already considerable resources devoted to
a therapeutic community approach in the UK prison system (for example, HMP
Grendon Underwood). The study could inform policy and resources decisions about
the management of antisocial personality disorder in the criminal justice system.
219
Summary of recommendations
8 SUMMARY OF RECOMMENDATIONS
GUIDANCE
8.1 GENERAL PRINCIPLES FOR WORKING WITH PEOPLE

WITH ANTISOCIAL PERSONALITY DISORDER
8.1.1 Access and assessment
8.1.1.1 People with antisocial personality disorder should not be excluded from
any health or social care service because of their diagnosis or history of
antisocial or offending behaviour.
8.1.1.2 Seek to minimise any disruption to therapeutic interventions for people
with antisocial personality disorder by:
● ensuring that in the initial planning and delivery of treatment, transfers
from institutional to community settings take into account the need to
continue treatment
● avoiding unnecessary transfer of care between institutions whenever
possible during an intervention, to prevent disruption to the agreed
treatment plan. This should be considered at initial planning of
treatment.
8.1.1.3 Ensure that people with antisocial personality disorder from black and
minority ethnic groups have equal access to culturally appropriate services
based on clinical need.
8.1.1.4 When language or literacy is a barrier to accessing or engaging with services
for people with antisocial personality disorder, provide:
● information in their preferred language and in an accessible format
● psychological or other interventions in their preferred language
● independent interpreters.
8.1.1.5 When a diagnosis of antisocial personality disorder is made, discuss the
implications of it with the person, the family or carers where appropriate,
and relevant staff, and:
● acknowledge the issues around stigma and exclusion that have charac-
terised care for people with antisocial personality disorder
● emphasise that the diagnosis does not limit access to a range of appro-
priate treatments for comorbid mental health disorders
● provide information on and clarify the respective roles of the health-
care, social care and criminal justice services.
8.1.1.6 When working with women with antisocial personality disorder take into
account the higher incidences of common comorbid mental health problems
220
and other personality disorders in such women, and:

● adapt interventions in light of this (for example, extend their duration)
● ensure that in inpatient and residential settings the increased vulnera-
bility of these women is taken into account.
8.1.1.7 Staff, in particular key workers, working with people with antisocial
personality disorder should establish regular one-to-one meetings to
review progress, even when the primary mode of treatment is group
based.
8.1.2 People with disabilities and acquired cognitive impairments
8.1.2.1 When a person with learning or physical disabilities or acquired cognitive

impairments presents with symptoms and behaviour that suggest antisocial
personality disorder, staff involved in assessment and diagnosis should
consider consulting with a relevant specialist.
8.1.2.2 Staff providing interventions for people with antisocial personality disor-
der with learning or physical disabilities or acquired cognitive impairments
should, where possible, provide the same interventions as for other people
with antisocial personality disorder. Staff might need to adjust the method
of delivery or duration of the intervention to take account of the disability
or impairment.
8.1.3 Autonomy and choice
8.1.3.1 Work in partnership with people with antisocial personality disorder to

develop their autonomy and promote choice by:
● ensuring that they remain actively involved in finding solutions to their
problems, including during crises
● encouraging them to consider the different treatment options and life
choices available to them, and the consequences of the choices they
make.
8.1.4 Developing and optimistic and trusting relationship
8.1.4.1 Staff working with people with antisocial personality disorder should
recognise that a positive and rewarding approach is more likely to be success-
ful than a punitive approach in engaging and retaining people in treatment.
Staff should:
● explore treatment options in an atmosphere of hope and optimism,
explaining that recovery is possible and attainable
221
● build a trusting relationship, work in an open, engaging and non-

judgemental manner, and be consistent and reliable.
8.1.5 Engagement and motivation
8.1.5.1 When providing interventions for people with antisocial personality

disorder, particularly in residential and institutional settings, pay attention
to motivating them to attend and engage with treatment. This should happen
at initial assessment and be an integral and continuing part of any interven-
tion, as people with antisocial personality disorder are vulnerable to prema-
ture withdrawal from treatment and supportive interventions.
8.1.6 Involving families and carers
8.1.6.1 Ask directly whether the person with antisocial personality disorder wants
their family or carers to be involved in their care, and, subject to the
person’s consent and rights to confidentiality:
● encourage families or carers to be involved
● ensure that the involvement of families or carers does not lead to a
withdrawal of, or lack of access to, services
● inform families or carers about local support groups for families or
carers.
8.1.6.2 Consider the needs of families and carers of people with antisocial person-
ality disorder and pay particular attention to the:
● impact of antisocial and offending behaviours on the family
● consequences of significant drug or alcohol misuse
● needs of and risks to any children in the family and the safeguarding
of their interests.
8.2 PREVENTION OF ANTISOCIAL PERSONALITY

DISORDER – WORKING WITH CHILDREN AND YOUNG
PEOPLE AND THEIR FAMILIES
8.2.1 General principles
8.2.1.1 Child and adolescent mental health service (CAMHS) professionals work-
ing with young people should:
● balance the developing autonomy and capacity of the young person
with the responsibilities of parents and carers
● be familiar with the legal framework that applies to young people,
including the Mental Capacity Act, the Children Acts and the Mental
Health Act.
222
8.2.2 Identifying children at risk of developing conduct problems
8.2.2.1 Services should establish robust methods to identify children at risk of

developing conduct problems, integrated when possible with the established
local assessment system. These should focus on identifying vulnerable
parents, where appropriate antenatally, including:
● parents with other mental health problems, or with significant drug or
alcohol problems.
● mothers younger than 18 years, particularly those with a history of
maltreatment in childhood
● parents with a history of residential care
● parents with significant previous or current contact with the criminal
justice system.
8.2.2.2 When identifying vulnerable parents, take care not to intensify any stigma
associated with the intervention or increase the child’s problems by labelling
them as antisocial or problematic.
8.2.3 Early interventions for preschool children at risk of developing conduct

problems and potentially subsequent antisocial personality disorder
8.2.3.1 Early interventions aimed at reducing the risk of the development of
conduct problems, and antisocial personality disorder at a later age, may be
considered for children identified to be of high risk of developing conduct
problems. These should be targeted at the parents of children with identified
high-risk factors and include:
● non-maternal care (such as well-staffed nursery care) for children
younger than 1 year
● interventions to improve poor parenting skills for the parents of children
younger than 3 years.
8.2.3.2 Early interventions should usually be provided by health and social care
professionals over a period of 6–12 months, and should:
● consist of well-structured, manualised programmes that are closely
adhered to
● target multiple risk factors (such as parenting, school behaviour, and
parental health and employment).
8.2.4 Interventions for children with conduct problems younger than 12

years and their families
8.2.4.1 Group-based parent-training/education programmes are recommended in
the management of children with conduct disorders.15
15This recommendation is from ‘Parent-training/education programmes in the management of children

with conduct disorders’ (NICE technology appraisal 102) (NICE, 2006b).
223
8.2.4.2 Individual-based parent-training/education programmes are recom-

mended in the management of children with conduct disorders only in situ-
ations where there are particular difficulties in engaging with the parents
or a family’s needs are too complex to be met by group-based parent-
training/education programmes.16
8.2.4.3 Additional interventions targeted specifically at the parents of children
with conduct problems (such as interventions for parental, marital or inter-
personal problems) should not be provided routinely alongside parent-
training programmes, as they are unlikely to have an impact on the child’s
conduct problems.
8.2.4.4 Programme providers should also ensure that support is available to enable
the participation of parents who might otherwise find it difficult to access
these programmes.17
8.2.4.5 Support to enable the participation of parents who might otherwise find it
difficult to access these programmes might include:
● individual parent-training programmes
● regular reminders about meetings (for example, telephone calls)
● effective treatment of comorbid disorders (in particular, attention
deficit hyperactivity disorder in line with ‘Attention deficit hyperactivity
disorder’, NICE clinical guideline 72).
8.2.5 How to deliver interventions for children with conduct

problems aged younger than 12 years and their families
8.2.5.1 It is recommended that all parent-training/education programmes, whether

group- or individual-based, should:18
● be structured and have a curriculum informed by principles of social-
learning theory
● include relationship-enhancing strategies
● offer a sufficient number of sessions, with an optimum of 8–12, to
maximise the possible benefits for participants
● enable parents to identify their own parenting objectives
● incorporate role-play during sessions, as well as homework to be under-
taken between sessions, to achieve generalisation of newly rehearsed
behaviours to the home situation
● be delivered by appropriately trained and skilled facilitators who are
supervised, have access to necessary ongoing professional development,
and are able to engage in a productive therapeutic alliance with parents
● adhere to the programme developer’s manual and employ all of the neces-
sary materials to ensure consistent implementation of the programme.
16Ibid.
17Ibid.
18Ibid.
224
8.2.5.2 Programmes should include problem solving (both for the parent and in
helping to train their child to solve problems) and the promotion of positive
behaviour (for example, through support, use of praise and reward).
8.2.5.3 Programmes should demonstrate proven effectiveness. This should be
based on evidence from randomised controlled trials or other suitable
rigorous evaluation methods undertaken independently.19
8.2.6 Cognitive behavioural interventions for children aged 8 years and

older with conduct problems
8.2.6.1 Cognitive problem-solving skills training should be considered for chil-

dren aged 8 years and older with conduct problems if:
● the child’s family is unwilling or unable to engage with a parent-
training programme (see Sections 8.2.4 and 8.2.5)
● additional factors, such as callous and unemotional traits in the child,
may reduce the likelihood of the child benefiting from parent-training
programmes alone.
8.2.6.2 For children who have residual problems following cognitive problem-
solving skills training, consider anger control or social problem-solving
skills training, depending on the nature of the residual problems.
8.2.7 How to deliver interventions for children aged 8 years

and older with conduct problems
8.2.7.1 Cognitive problem-solving skills training should be delivered individually

over a period of 10–16 weeks. Training should focus typically on cognitive
● generate a range of alternative solutions to interpersonal problems
● analyse the intentions of others
● understand the consequences of their actions
● set targets for desirable behaviour.
8.2.7.2 Anger control should usually take place in groups over a period of 10–16
weeks and focus typically on strategies to enable the child to:
● build capacity to improve the perception and interpretation of social cues
● manage anger through coping and self-talk
● generate alternative ‘non-aggressive’ responses to interpersonal problems.
8.2.7.3 Social problem-solving skills training should usually be conducted in
groups over a period of 10–16 weeks. Training should focus typically on
● modify and expand their interpersonal appraisal processes
19Ibid.
225
● develop a more sophisticated understanding of beliefs and desires in

others
● improve their capacity to regulate their emotional responses.
8.2.8 Interventions for young people with conduct problems aged

between 12 and 17 years and their families
8.2.8.1 For parents of young people aged between 12 and 17 years with conduct
problems, consider parent-training programmes (see Sections 8.2.4 and 8.2.5).
8.2.8.2 If the parents are unable to or choose not to engage with parent-training
programmes, or the young person’s conduct problems are so severe that they
will be less likely to benefit from parent-training programmes, consider:
● brief strategic family therapy for those with predominantly drug-
related problems
● functional family therapy for those with predominantly a history of
offending.
8.2.8.3 For young people aged between 12 and 17 years with severe conduct prob-
lems and a history of offending and who are at risk of being placed in care
or excluded from the family, consider multisystemic therapy.
8.2.8.4 For young people aged between 12 and 17 years with conduct problems at
risk of being placed in long-term out-of-home care, consider multidimen-
sional treatment foster care.
8.2.9 How to deliver interventions for young people with conduct problems
aged between 12 and 17 years and their families
8.2.9.1 Brief strategic family therapy should consist of at least fortnightly meet-
ings over a period of 3 months and focus on:
● engaging and supporting the family
● engaging and using the support of the wider social and educational
system
● identifying maladaptive family interactions (including areas of power
distribution and conflict resolution)
● promoting new and more adaptive family interactions (including open
and effective communication).
8.2.9.2 Functional family therapy should be conducted over a period of 3 months
by health or social care professionals and focus on improving the inter-
actions within the family, including:
● engaging and motivating the family in treatment (enhancing perception
that change is possible, positive reframing and establishing a positive
alliance)
● problem-solving and behaviour change through parent-training and
communication training
226
● promoting generalisation of change in specific behaviours to broader

contexts, both within the family and the community (such as
schools).
8.2.9.3 Multisystemic therapy should be provided over a period of 3–6 months by
a dedicated professional with a low caseload, and should:
● focus specifically on problem-solving approaches with the family
● involve and use the resources of peer groups, schools and the wider
community.
8.2.9.4 Multidimensional treatment foster care should be provided over a period of
6 months by a team of health and social care professionals able to provide
case management, individual therapy and family therapy. This intervention
should include:
● training foster care families in behaviour management and providing a
supportive family environment
● the opportunity for the young person to earn privileges (such as time
on the computer and extra telephone time with friends) when engaging
in positive living and social skills (for example, making their bed and
being polite) and good behaviour at school
● individual problem-solving skills training for the young person
● family therapy for the birth parents to provide a supportive environ-
ment for the young person to return to after treatment.
8.2.10 Transition from child and adolescent services to adult services
8.2.10.1 Health and social care services should consider referring vulnerable young
people with a history of conduct disorder or contact with youth offending
schemes, or those who have been receiving interventions for conduct and
related disorders, to appropriate adult services for continuing assessment
and/or treatment.
8.3 ASSESSMENT AND RISK MANAGEMENT OF ANTISOCIAL

8.3.1 Assessment
8.3.1.1 When assessing a person with possible antisocial personality disorder,

healthcare professionals in secondary and forensic mental health services
should conduct a full assessment of:
● antisocial behaviours
● personality functioning, coping strategies, strengths and vulnerabilities
● comorbid mental disorders (including depression and anxiety, drug or
alcohol misuse, post-traumatic stress disorder and other personality
disorders)
227
● the need for psychological treatment, social care and support, and
occupational rehabilitation or development
● domestic violence and abuse.
8.3.1.2 Staff involved in the assessment of antisocial personality disorder in
secondary and specialist services should use structured assessment meth-
ods whenever possible to increase the validity of the assessment. For foren-
sic services, the use of measures such as PCL-R or PCL-SV to assess the
severity of antisocial personality disorder should be part of the routine
assessment process.
8.3.1.3 Staff working in primary and secondary care services (for example, drug
and alcohol services) and community services (for example, the probation
service) that include a high proportion of people with antisocial personal-
ity disorder should be alert to the possibility of antisocial personality disor-
der in service users. Where antisocial personality disorder is suspected and
the person is seeking help, consider offering a referral to an appropriate
forensic mental health service depending on the nature of the presenting
complaint. For example, for depression and anxiety this may be to general
mental health services; for problems directly relating to the personality
disorder it may be to a specialist personality disorder or forensic service.
8.3.2 Risk assessment and management
Primary care services

8.3.2.1 Assessing risk of violence is not routine in primary care, but if such assess-
ment is required consider:
itants and victims
● the presence of comorbid mental disorders and/or substance misuse
(subject to the person’s consent and right to confidentiality), because
the person with antisocial personality disorder might not always be a
8.3.2.2 Healthcare professionals in primary care should consider contact with
and/or referral to secondary or forensic services where there is current
violence or threats that suggest significant risk and/or a history of serious
violence, including predatory offending or targeting of children or other
vulnerable people.
Secondary care services

8.3.2.3 When assessing the risk of violence in secondary care mental health
services, take a detailed history of violence and consider and record:
itants and victims
228

person with antisocial personality disorder might not always be a
8.3.2.4 The initial risk management should be directed at crisis resolution and
ameliorating any acute aggravating factors. The history of previous
violence should be an important guide in the development of any future
violence risk management plan.
8.3.2.5 Staff in secondary care mental health services should consider a referral to
forensic services where there is:
● current violence or threat that suggests immediate risk or disruption to
the operation of the service
● a history of serious violence, including predatory offending or targeting
of children or other vulnerable people.
Specialist personality disorder or forensic services

8.3.2.6 When assessing the risk of violence in forensic, specialist personality
disorder or tertiary mental health services, take a detailed history of violence,
and consider and record:
● current and previous violence, including severity, circumstances,
precipitants and victims
person with antisocial personality disorder might not always be a
8.3.2.7 Healthcare professionals in forensic or specialist personality disorder services
should consider, as part of a structured clinical assessment, routinely using:
● a standardised measure of the severity of antisocial personality disorder
(for example, PCL-R or PCL-SV)
● a formal assessment tool such as HCR-20 to develop a risk manage-
ment strategy.
8.3.3 Risk management
8.3.3.1 Services should develop a comprehensive risk management plan for people
with antisocial personality disorder who are considered to be of high risk.
229
The plan should involve other agencies in health and social care services
and the criminal justice system. Probation services should take the lead
role when the person is on a community sentence or is on licence from
prison with mental health and social care services providing support and
liaison. Such cases should routinely be referred to the local Multi-Agency
Public Protection Panel.
8.4 TREATMENT AND MANAGEMENT OF ANTISOCIAL

PERSONALITY DISORDER AND RELATED AND COMORBID
DISORDERS
8.4.1 General principles
8.4.1.1 People with antisocial personality disorder should be offered treatment for
any comorbid disorders in line with recommendations in the relevant NICE
clinical guideline, where available. This should happen regardless of
whether the person is receiving treatment for antisocial personality disorder.
8.4.1.2 When providing psychological or pharmacological interventions for anti-
social personality disorder, offending behaviour or comorbid disorders to
people with antisocial personality disorder, be aware of the potential for
and possible impact of:
● poor concordance
● high attrition
● misuse of prescribed medication
● drug interactions (including with alcohol and illicit drugs).
8.4.1.3 When providing psychological interventions for comorbid disorders to
people with antisocial personality disorder, consider lengthening their
duration or increasing their intensity.
8.4.2 The role of psychological interventions
8.4.2.1 For people with antisocial personality disorder, including those with
substance misuse problems, in community and mental health services,
consider offering group-based cognitive and behavioural interventions, in
order to address problems such as impulsivity, interpersonal difficulties
and antisocial behaviour.
8.4.2.2 For people with antisocial personality disorder with a history of offending
behaviour who are in community and institutional care, consider offering
group-based cognitive and behavioural interventions (for example,
programmes such as ‘Reasoning and Rehabilitation’) focused on reducing
offending and other antisocial behaviour.
8.4.2.3 For young offenders aged 17 years or younger with a history of offending
behaviour who are in institutional care, offer group-based cognitive and
230
behavioural interventions aimed at young offenders and that are focused on

reducing offending and other antisocial behaviour.
8.4.2.4 When providing cognitive and behavioural interventions:
● assess the level of risk and adjust the duration and intensity of the
programme accordingly (participants at all levels of risk may benefit
from these interventions)
● provide support and encouragement to help participants to attend and
complete programmes, including people who are legally mandated to
do so.
8.4.3 The role of pharmacological interventions

8.4.3.1 Pharmacological interventions should not be routinely used for the treatment
of antisocial personality disorder or associated behaviours of aggression,
anger and impulsivity.
8.4.3.2 Pharmacological interventions for comorbid mental disorders, in particular
depression and anxiety, should be in line with recommendations in the
relevant NICE clinical guideline. When starting and reviewing medication
for comorbid mental disorders, pay particular attention to issues of adher-
ence and the risks of misuse or overdose.
8.4.4 Drug and alcohol misuse

8.4.4.1 For people with antisocial personality disorder who misuse drugs, in
particular opioids or stimulants, offer psychological interventions (in partic-
ular, contingency management programmes) in line with recommendations
in the relevant NICE clinical guideline.
8.4.4.2 For people with antisocial personality disorder who misuse or are depend-
ent on alcohol, offer psychological and pharmacological interventions in
line with existing national guidance for the treatment and management of
alcohol disorders.
8.4.4.3 For people with antisocial personality disorder who are in institutional care
and who misuse or are dependent on drugs or alcohol, consider referral to
a specialist therapeutic community focused on the treatment of drug and
alcohol problems.
8.5 PSYCHOPATHY AND DANGEROUS AND SEVERE

8.5.1 Adapting interventions for people who meet criteria for
psychopathy or DSPD
8.5.1.1 For people in community and institutional settings who meet criteria for
psychopathy or DSPD, consider cognitive and behavioural interventions
(for example, programmes such as ‘Reasoning and Rehabilitation’) focused
231
on reducing offending and other antisocial behaviour. These interventions

should be adapted for this group by extending the nature (for example,
concurrent individual and group sessions) and duration of the intervention,
and by providing booster sessions, continued follow-up and close
monitoring.
8.5.1.2 For people who meet criteria for psychopathy or DSPD, offer treatment for
any comorbid disorders in line with existing NICE guidance. This should
happen regardless of whether the person is receiving treatment for psychopa-
thy or DSPD because effective treatment of comorbid disorders may reduce
the risk associated with psychopathy or DSPD.
8.5.2 Intensive staff support
8.5.2.1 Staff providing interventions for people who meet criteria for psychopathy
or DSPD should receive high levels of support and close supervision, due
to increased risk of harm. This may be provided by staff outside the unit.
8.6 ORGANISATION AND PLANNING OF SERVICES
8.6.1 Multi-agency care
8.6.1.1 Provision of services for people with antisocial personality disorder often
involves significant inter-agency working. Therefore, services should ensure
that there are clear pathways for people with antisocial personality disor-
der so that the most effective multi-agency care is provided. These pathways
should:
● specify the various interventions that are available at each point
● enable effective communication among clinicians and organisations at
all points and provide the means to resolve differences and disagree-
ments.
Clearly agreed local criteria should also be established to facilitate the
transfer of people with antisocial personality disorder between services.
As far as is possible, shared objective criteria should be developed relat-
ing to comprehensive assessment of need and risk.
8.6.1.2 Services should consider establishing antisocial personality disorder
networks, where possible linked to other personality disorder networks.
(They may be organised at the level of primary care trusts, local authori-
ties, strategic health authorities or government offices.) These networks
should be multi-agency, should actively involve people with antisocial
personality disorder and should:
● take a significant role in training staff, including those in primary care,
general, secondary and forensic mental health services, and in the
criminal justice system
232
● have resources to provide specialist support and supervision for staff

● take a central role in the development of standards for and the coordi-
nation of clinical pathways
● monitor the effective operation of clinical pathways.
8.6.2 Inpatient services
8.6.2.1 Healthcare professionals should normally only consider admitting people

with antisocial personality disorder to inpatient services for crisis manage-
ment or for the treatment of comorbid disorders. Admission should be brief,
where possible set out in a previously agreed crisis plan and have a defined
purpose and end point.
8.6.2.2 Admission to inpatient services solely for the treatment of antisocial
personality disorder or its associated risks is likely to be a lengthy process
and should:
● be under the care of forensic/specialist personality disorder services
● not usually be under a hospital order under a section of the Mental
Health Act (in the rare instance that this is done, seek advice from a
forensic/specialist personality service).
8.6.3 Staff training, supervision, support
Staff competencies
be familiar with the ‘Ten essential shared capabilities: a framework for the
whole of the mental health practice’20 and have a knowledge and aware-
ness of antisocial personality disorder that facilitates effective working
with service users, families or carers, and colleagues.
have skills appropriate to the nature and level of contact with service users.
These skills include:
● for all frontline staff, knowledge about antisocial personality disorder
and understanding behaviours in context, including awareness of the
potential for therapeutic boundary violations (for example, inappropri-
ate relations with service users)
● for staff with regular and sustained contact with people with antisocial
personality disorder, the ability to respond effectively to the needs of
service users
● for staff with direct therapeutic or management roles, competence in
the specific treatment interventions and management strategies used in
the service.
20Available from www.eftacim.org/doc_pdf/10ESC.pdf
233
8.6.3.3 Services should ensure that all staff providing psychosocial or pharmaco-
logical interventions for the treatment or prevention of antisocial personal-
ity disorder are competent and properly qualified and supervised, and that
they adhere closely to the structure and duration of the interventions as set
out in the relevant treatment manuals. This should be achieved through:
● use of competence frameworks based on relevant treatment manuals
● routine use of sessional outcome measures
● routine direct monitoring and evaluation of staff adherence, for exam-
ple through the use of video and audio tapes and external audit and
scrutiny where appropriate.
Supervision and support

8.6.3.4 Services should ensure that staff supervision is built into the routine work-
ing of the service, is properly resourced within local systems and is moni-
tored. Supervision, which may be provided by staff external to the service,
should:
● make use of direct observation (for example, recordings of sessions)
and routine outcome measures
● support adherence to the specific intervention
● promote general therapeutic consistency and reliability
● counter negative attitudes among staff.
8.6.3.5 Forensic services should ensure that systems for all staff working with
people with antisocial personality disorder are in place that provide:
● comprehensive induction programmes in which the purpose of the
service is made clear
● a supportive and open environment that encourages reflective practice
and honesty about individual difficulties such as the potential for ther-
apeutic boundary violations (such as inappropriate relations with serv-
ice users)
● continuing staff support to review and explore the ethical and clinical
challenges involved in working in high-intensity environments,
thereby building staff capacity and resilience.
RESEARCH RECOMMENDATIONS
8.7 SEVERITY AS A POTENTIAL MODERATOR OF EFFECT

IN GROUP-BASED COGNITIVE AND BEHAVIOURAL
INTERVENTIONS
Does the pre-treatment level of the severity of disorder/problem have an impact on the
outcome of group-based cognitive and behavioural interventions for offending behav-
iour? A meta-analysis of individual participant data should be conducted to determine
whether the level of severity assessed at the beginning of the intervention moderates
the effect of the intervention. The study (for which there are large data sets that
234
include over 10,000 participants) could inform the design of a large-scale RCT
(including potential modifications of cognitive and behavioural interventions) to test
the impact of severity on the outcome of cognitive and behavioural interventions.

Research has established the efficacy of cognitive and behavioural interventions in
reducing re-offending. However, the effects of these interventions in a range of offend-
ing populations are modest. The impact of severity on the outcome of these interventions
has not been systematically investigated, and post hoc analyses and meta-regression of
risk as a moderating factor have been inconclusive. Expert opinion suggests that severe
or high-risk individuals may not benefit from cognitive and behavioural interventions,
but if they were to be of benefit then the cost savings could be considerable.
8.8 GROUP-BASED COGNITIVE AND BEHAVIOURAL

INTERVENTIONS FOR POPULATIONS OUTSIDE CRIMINAL
JUSTICE SETTINGS
Are group-based cognitive and behavioural interventions effective in reducing the

behaviours associated with antisocial personality disorder (such as impulsivity, rule-
breaking, deceitfulness, irritability, aggressiveness and disregard for the safety of self
or others)? This should be tested in an RCT that examines medium-term outcomes
(including cost effectiveness) over a period of at least 18 months. It should pay partic-
ular attention to the modification and development of the interventions to ensure the
focus is not just on offending behaviour, but on all aspects of the challenging behav-
iours associated with antisocial personality disorder.

Not all people with antisocial personality disorder are offenders but they exhibit a
wide range of antisocial behaviours. However, the evidence for the treatment of these
behaviours outside the criminal justice system is extremely limited. Following publi-
cation of the Department of Health’s policy guidance, ‘Personality disorder: no longer
a diagnosis of exclusion’ (2003), it is likely that there will be an increased require-
ment in the NHS to offer treatments for antisocial personality disorder.
8.9 EFFECTIVENESS OF MULTISYSTEMIC THERAPY VERSUS

FUNCTIONAL FAMILY THERAPY
Is multisystemic therapy or functional family therapy more clinically and cost effec-
tive in the treatment of adolescents with conduct disorders? A large-scale RCT
comparing the clinical and cost effectiveness of multisystemic therapy and functional
family therapy for adolescents with conduct disorders should be conducted. It should
examine the medium-term outcomes (for example, offending behaviour, mental state,
educational and vocational outcomes and family functioning) over a period of at least
235
18 months. The study should also be designed to explore the moderators and media-
tors of treatment effect, which could help to determine the factors associated with
benefits or harms of either multisystemic therapy or functional family therapy.

Multisystemic therapy and functional family therapy are two interventions with a
relatively strong evidence base in the treatment of adolescents with conduct disorders,
but there have been no studies directly comparing their clinical and cost effectiveness.
Their use in health and social care services in the UK is increasing. Both interven-
tions target the same population, but although they share some common elements
(that is, work with the family), multisystemic therapy is focused on both the family
and the wider resources of the school, community and criminal justice systems, and
through intensive individual case work seeks to change the pattern of antisocial
behaviour. In contrast, functional family therapy focuses more on the immediate
family environment and uses the resources of the family to change the pattern of
antisocial behaviour. The study should be designed to facilitate the identification of
subgroups within the conduct disorder population who may benefit from either multi-
systemic therapy or functional family therapy.
8.10 INTERVENTIONS FOR INFANTS AT HIGH RISK

OF DEVELOPING CONDUCT DISORDERS
Do specially designed parent-training programmes focused on sensitivity enhance-

ment (a set of techniques designed to improve secure attachment behaviour between
parents and children) reduce the risk of behavioural disorders, including conduct
problems and delinquency, in infants at high risk of developing these problems? An
RCT comparing parent-training programmes focused on sensitivity enhancement
with usual care should be undertaken. It should examine the long-term outcomes over
a period of at least 5 years, but with consideration given to the possibility of a further
10-year follow-up. The study should also be designed to explore the moderators and
mediators of treatment effect that could help determine the factors associated with
benefits or harms of the intervention.

There is limited evidence from non-UK studies that interventions focused on devel-
oping better parent–child attachment can have benefits for infants at risk of develop-
ing conduct disorder. Determining the criteria and then identifying children at high
risk (usually via parental risk factors) is difficult and challenging. Even when these
factors are agreed, engaging parents in treatment can be difficult. It is important that
a range of effective interventions is developed to increase the treatment choice and
opportunities for high-risk groups. Several interventions, such as Nurse–Family
Practitioners, are being developed and trialled in the UK. It is important for this group
of children to have an alternative, effective intervention.
236
8.11 TREATMENT OF COMORBID ANXIETY DISORDERS

IN ANTISOCIAL PERSONALITY DISORDER
Does the effective treatment of anxiety disorders in antisocial personality disorder

improve the long-term outcome for antisocial personality disorder? An RCT of
people with antisocial personality disorder and comorbid anxiety disorders that
compares a sequenced treatment programme for the anxiety disorder with usual care
should be conducted. It should examine, over a period of at least 18 months, the
medium-term outcomes for key symptoms and behaviours associated with antisocial
personality disorder (including offending behaviour, deceitfulness, irritability and
aggressiveness, and disregard for the safety of self or others), as well as drug and
alcohol misuse, and anxiety. The study should also be designed to explore the moder-
ators and mediators of treatment effect which could help determine the role of anxi-
ety in the course of antisocial personality disorder.

Comorbidity with Axis I disorders is common in antisocial personality disorder,
and chronic anxiety has been identified as a particular disorder that may exacer-
bate the problems associated with antisocial personality disorder. There are
effective treatments (psychological and pharmacological) for anxiety disorders but
they are often not offered to people with antisocial personality disorder. Current
treatment guidelines set out clear pathways for the stepped or sequenced care of
people with anxiety disorders. An RCT to test the benefit of this approach in the
treatment of anxiety would potentially lead to a significant reduction in illness
burden but a reduction in antisocial behaviour would have wider societal benefits.
The study should provide important information on the challenges of delivering
these interventions for a population that has typically both rejected and been
refused treatment.
8.12 USING SELECTIVE SEROTONIN REUPTAKE INHIBITORS

TO INCREASE COOPERATIVE BEHAVIOUR IN PEOPLE
WITH ANTISOCIAL PERSONALITY DISORDER IN A
PRISON SETTING
Although there is evidence that selective serotonin reuptake inhibitors (SSRIs), such
as paroxetine, increase cooperative behaviour in normal people and do so independ-
ently of the level of sub-syndromal depression, this has yet to be tested in other
settings. Given that people with antisocial personality disorder are likely to have
difficulties cooperating with one another (because of a host of personality traits that
include persistent rule-breaking for personal advantage, suspiciousness, grandiosity,
etc.), an RCT should be conducted to find out whether these reported changes of
behaviour with an SSRI in normal people generalises to clinical populations in
different settings.
237

There is little evidence in the literature on the pharmacotherapy of antisocial person-
ality disorder to justify the use of any particular medication. However, multiple drugs
in various combinations are used in this group either to control aberrant behaviour or
in the hope that something might work. Current interventions lack a clear rationale.
This recommendation has the potential to advance the field in that (a) it is linked to a
clear hypothesis (that cooperative behaviour is linked to a dysregulation of the serotonin
receptors – for which there is substantial evidence) and (b) that it is feasible to obtain
an answer to this question, given that there are a large number of individuals detained
in prison settings who would meet ASPD criteria. Constructing an experimental task
that requires cooperative activity would not be difficult in such a setting, since all of
those who might be willing to participate are already detained. The successful execu-
tion of this research would be important in that it (a) would establish the feasibility
of conducting such a trial in a prison setting with this group, and (b) provide a clear
and sensible outcome measure of antisocial behaviour that might be generalised to
other settings.
8.13 A THERAPEUTIC COMMUNITY APPROACH FOR

ANTISOCIAL PERSONALITY DISORDER IN A
PRISON SETTING
Is a therapeutic community approach in a prison setting more clinically and cost

effective in the treatment and management of antisocial personality disorder than
routine prison care? There should be a large-scale RCT comparing the clinical and
cost effectiveness of the therapeutic community approach for adults with antisocial
personality disorder with routine care. It should examine the medium-term outcomes
(for example, offending behaviour, mental state and vocational outcomes) over a
period of at least 18 months following release from prison. The study should also be
designed to explore the moderators and mediators of treatment effect, which could
help to determine the factors associated with benefits or harms of the therapeutic
community approach.

There is evidence from RCTs that the therapeutic community approach is of value
with drug and alcohol misusers in a prison setting at reducing the incidence of offend-
ing behaviour on release. However, there are no equivalent studies of a programme in
the prison system on antisocial personality disorder populations that do not have
significant drug or alcohol problems. Data that do exist are from non-UK settings.
Answering this question is of importance because outcomes for adults with antisocial
personality disorder are poor and there are already considerable resources devoted to
a therapeutic community approach in the UK prison system (for example, HMP
Grendon Underwood). The study could inform policy and resources decisions about
the management of antisocial personality disorder in the criminal justice system.
238
Appendices
9. APPENDICES
Appendix 1: Scope for the development of the clinical guideline 240
Appendix 2: Declarations of interests by GDG members 249
Appendix 3: Special advisers to the Guideline Development Group 261
Appendix 4: Stakeholders who responded to early requests for evidence 262
Appendix 5: Stakeholders and experts who submitted comments in

response to the consultation draft of the guideline 263
Appendix 6: Researchers contacted to request information about

unpublished or soon-to-be published studies 264
Appendix 7: Analytic framework and clinical questions 265
Appendix 8: Search strategies for the identification of clinical studies 281
Appendix 9: Clinical study data extraction form 284
Appendix 10: Quality checklists for clinical studies and reviews 285
Appendix 11: Search strategies for the identification of health

economics evidence 299
Appendix 12: Quality checklists for economic studies 301
Appendix 13: Data extraction form for economic studies 304
Appendix 14: Evidence tables for economic studies 307
Appendix 15: Characteristics of reviewed studies On CD
Appendix 16: Clinical evidence forest plots On CD
Appendix 17: Characteristics of studies on risk factors for

developing antisocial personality disorder On CD
239
Appendix 1
APPENDIX 1:
SCOPE FOR THE DEVELOPMENT OF THE
CLINICAL GUIDELINE
Final version
14 March 2007
GUIDELINE TITLE
Antisocial personality disorder: treatment, management and prevention
Short title
Antisocial personality disorder (ASPD)21
BACKGROUND
The National Institute for Health and Clinical Excellence (‘NICE’ or ‘the Institute’)
has commissioned the National Collaborating Centre for Mental Health to develop a
clinical guideline on antisocial personality disorder for use in the NHS in England and
Wales. This follows referral of the topic by the Department of Health (see Appendix
[to the Scope]). The guideline will provide recommendations for good practice that are
based on the best available evidence of clinical and cost effectiveness.
The Institute’s clinical guidelines will support the implementation of National
Service Frameworks (NSFs) in those aspects of care where a Framework has been
published. The statements in each NSF reflect the evidence that was used at the time
the Framework was prepared. The clinical guidelines and technology appraisals
published by the Institute after an NSF has been issued will have the effect of updat-
ing the Framework.
NICE clinical guidelines support the role of healthcare professionals in providing
care in partnership with patients, taking account of their individual needs and prefer-
ences, and ensuring that patients (and their carers and families, where appropriate)
can make informed decisions about their care and treatment.
21There were minor changes to the short title in the development period to ‘Antisocial personality
disorder’.
240
Appendix 1
CLINICAL NEED FOR THE GUIDELINE
Personality disorders are long-standing and maladaptive patterns of perceiving and

responding to other people and to stressful circumstances. Antisocial personality
disorder is characterised by a gross disparity between behaviour and the prevailing
social norms and a pervasive pattern of disregard for, and violation of, the rights of
others that begins in childhood or early adolescence and continues into adulthood. It
is one of the most common of the personality disorders and is strongly associated
with social impairment, offending behaviours and increased risks of both mental and
physical health problems, particularly substance misuse (including alcoholism).
General diagnostic criteria for a personality disorder must be met for a diagnosis
of antisocial personality disorder. There are two main sets of diagnostic criteria in
current use, the International Classification of Mental and Behavioural Disorders 10th
Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders
fourth edition (DSM-IV). General criteria for personality disorders are similar in ICD-
10 and DSM-IV. Both require an individual to have an enduring pattern of inner expe-
rience and behaviour that deviates markedly from the expectations of their culture, is
pervasive and inflexible across a range of situations, leads to significant distress or
impairment, is stable and of long duration (with onset in childhood, adolescence or
early adulthood), and cannot be explained as a manifestation or consequence of other
mental disorders, substance use, or organic brain disease, injury or dysfunction.
Diagnostic criteria for antisocial personality disorder are broadly similar in both
ICD-10 and DSM-IV, although the latter has a heavy emphasis on criminality.
ICD-10 uses the term dissocial personality disorder, which is characterised by at least
three of the following features: a disregard for the feelings of others and social norms,
rules and obligations; gross and persistent irresponsibility; incapacity to maintain
relationships; a low tolerance to frustration and a low threshold for aggression and
violence; incapacity to experience guilt or learn from experience (including punish-
ment); and a tendency to blame others or offer rational explanations for antisocial
behaviour. Additional criteria included in the DSM-IV definition of antisocial person-
ality disorder are repeatedly performing acts that are grounds for arrest, deceitfulness,
impulsiveness, and a disregard for the safety of others. DSM-IV criteria do not
include lack of concern for the feeling of others and incapacity to maintain relation-
ships or profit from experience.
Antisocial personality disorder can only be diagnosed in adults. In ICD-10 the
specific personality disorders come within the overall grouping of disorders of adult
personality. In DSM-IV antisocial personality disorder cannot be diagnosed in those
under 18 years of age, although a number of juvenile criteria (that is, features present
before the age of 15) are specified that must be met in addition to abnormal behav-
iour in adulthood.
ICD-10 notes that people with personality disorders may have other coexisting or
superimposed mental disorders, behavioural syndromes and developmental disorders.
In DSM-IV common comorbidities in people with antisocial personality disorder
include anxiety and depressive disorders, mood disorders, substance-related disor-
ders, somatisation disorder, pathological gambling and other disorders of impulse
241
Appendix 1
control. DSM-IV also notes that while the personality disorders have overlapping
features and must be distinguished from one another by their distinguishing features,
they can (and often do) co-occur.
Antisocial, aggressive or criminal behaviour that does not meet the full criteria for
antisocial personality disorder is described as adult antisocial behaviour in DSM-IV,
with the diagnosis of antisocial personality disorder only applying to those whose
antisocial personality traits are inflexible, maladaptive and persistent, and a cause of
significant impairment or distress. Antisocial personality disorder is distinguished
from criminal behaviour for gain where the characteristic features of antisocial
personality disorder are absent.
The aetiology of antisocial personality disorder is uncertain. Antisocial personal-
ity disorder may be the consequence of the accumulation and interaction of multiple
factors through development, including temperament, childhood and adolescent expe-
riences, and other environmental factors. The risk factor most predictive of adult anti-
social personality is the severity and extent of child and adolescent conduct symptoms
and a history of childhood or adolescent conduct disorder is common in people with
antisocial personality disorder (and is one of the diagnostic criteria in DSM-IV).
Other childhood and adolescent risk factors for adult antisocial personality disorder
include other psychopathology (particularly depression, oppositional disorder, and
substance misuse) and callous temperament.
Childhood and adolescent risk factors associated with the broader category of adult
antisocial behaviour include: individual characteristics such as an undercontrolled,
impulsive, aggressive or hyperactive temperament, low IQ and poor educational
achievement; family factors such as having an antisocial parent, poor supervision,
abuse and violence between parents; and wider societal factors such as an antisocial
peer group and high levels of delinquency in school. Risk factors for antisocial behav-
iour are often correlated with one another. A number of childhood factors are protec-
tive against the development of later antisocial behaviour, including temperamental
characteristics such as shyness and inhibition, intelligence, a close relationship with at
least one adult, good school or sporting achievement, and non-antisocial peers.
Neurobiological mechanisms for antisocial personality disorder and antisocial behav-
iour have also been proposed and there is evidence that there is a genetic component in
the development of antisocial behaviour. It has been proposed that a genetic predisposi-
tion may increase the likelihood that exposures to adverse environmental influences and
life events will lead to the development of antisocial personality disorder.
The personality disorders are associated with a significant burden to the individ-
ual, those around them and society as a whole, with the impact of the disorder gener-
ally being greatest in early adulthood and diminishing with age. Their families
commonly endure episodes of explosive anger and rage, a callous and unemotional
behavioural pattern, depression, self-harm, and suicide attempts. Antisocial personal-
ity disorder is also associated with significant drug and alcohol misuse, with further
attendant costs to the individual, their family and society.
The antisocial, violent and offending behaviour associated with antisocial person-
ality disorder has a negative impact across society and results in a range of costs to
society including those to victims of the behaviour (including physical harm and the
242
Appendix 1
impact of intimidation and fear), the costs of policing and other national and local
measures to curb antisocial behaviour, and general costs to the criminal justice system
including the costs of detention and other punitive measures.
People with personality disorders tend to make heavy but dysfunctional demands
on services, having frequent contact with mental health and social services, A&E,
GPs and the criminal justice system, and may be high-cost, persistent, and intensive
users of mental health services.
Some people with antisocial personality disorder will also be categorised as
having a dangerous and severe personality disorder (DSPD). DSPD is not a diagnos-
tic category; rather, it is a term used to describe a category of dangerous offenders
whose offending is linked to severe personality disorder and who present a very high
risk of serious violent and/or sexual offending. People in this category will have
committed a violent and/or sexual crime and may have been detained under the crim-
inal justice system or mental health legislation.
The prevalence of antisocial personality disorder in the general population of
Great Britain has been estimated at 0.6%, with the rate in men (1%) five times that in
women (0.2%). Surveys conducted in other countries report prevalence rates for anti-
social personality disorder ranging from 0.2 to 4.1%. Higher prevalence rates for
personality disorders appear to be found in urban populations and this may account
for some of the range in reported prevalence – the estimate of 0.6% for the prevalence
of antisocial personality disorder in Great Britain was based on data gathered from a
survey covering a range of locations.
Antisocial personality disorder is common among drug and alcohol misusers in
both treatment and custodial settings. The prevalence of personality disorders, and
antisocial personality disorder in particular, is particularly high in the prison popula-
tion. In England and Wales 78% of male remand prisoners, 64% of male sentenced
prisoners, and 50% of female prisoners have personality disorders, with the preva-
lence of antisocial personality disorder being 63% among male remand prisoners (just
over half of whom have antisocial personality disorder plus another personality disor-
der), 49% among sentenced male prisoners (two fifths of whom have antisocial
personality disorder plus another personality disorder) and 31% among female pris-
oners (two thirds of whom have antisocial personality disorder plus another person-
ality disorder).
Many clinicians are sceptical about the effectiveness of treatment interventions for
personality disorder, and hence often reluctant to accept people with a primary diagno-
sis of personality disorder for treatment. Established antisocial personality disorder is
difficult to treat and evidence on the effectiveness of therapeutic interventions is sparse.
The diagnosis of antisocial personality disorder requires evidence that the features
of the disorder onset in childhood or adolescence (ICD-10) or evidence of conduct
disorder with onset before age 15 years (DSM-IV) and this, combined with the diffi-
culty of treating adult antisocial personality disorder, has led to a focus on preventa-
tive interventions with children and young people at risk of later antisocial personality
disorder. Early prevention during childhood may be desirable, but many individuals
who go on to develop adult antisocial personality disorder are not identified before
adolescence.
243
Appendix 1
It should be noted that a separate guideline on borderline personality disorder is

being developed in parallel to the development of the antisocial personality disorder
guideline. Beyond the differences in the diagnostic criteria for borderline personality
disorder and antisocial personality disorder, there are good grounds for developing
two separate guidelines for these disorders, rather than one unified guideline on
personality disorders, as there are marked differences in the populations the guide-
lines will address in terms of their interaction with services. People with borderline
personality disorder tend to be treatment seeking and at high risk of self-harm and
suicide, whereas people with antisocial personality disorder tend not to seek treat-
ment, are likely to come into contact with services via the criminal justice system and
their behaviour is more likely to be a risk to others. Nevertheless, it is acknowledged
that people with either of these diagnoses may present with some symptoms and
behaviour normally associated with the other diagnosis.
THE GUIDELINE
The guideline development process is described in detail in two publications which are
available from the NICE website22 (see ‘About NICE’ » ‘How we work’ » ‘Developing
NICE clinical guidelines’ » ‘Clinical guideline development methods’). An overview
for stakeholders, the public and the NHS (2006 edition) describes how organisations
can become involved in the development of a guideline. The guidelines manual (2006
edition) provides advice on the technical aspects of guideline development.
This document is the scope. It defines exactly what this guideline will (and will
not) examine, and what the guideline developers will consider. The scope is based on
the referral from the Department of Health (see Appendix [to the Scope]). The areas
that will be addressed by the guideline are described in the following sections.
POPULATION
Groups that will be covered
The recommendations in this guideline will address the following:

● The treatment and management of adults with a diagnosis of antisocial personal-
ity disorder in the NHS and prison system (including dangerous and severe
personality disorder).
● Preventative interventions with children and adolescents at significant risk of
developing antisocial personality disorder.
● The treatment and management of common comorbidities in people with antiso-
cial personality disorder as far as these conditions affect the treatment of antiso-
cial personality disorder.
22www.nice.org.uk
244
Appendix 1
Groups that will not be covered
The guideline will not cover:

● The separate management of comorbid conditions.
● The management of criminal and antisocial behaviour in the absence of a diagno-
sis of antisocial personality disorder.
HEALTHCARE SETTING
The guideline will cover the care provided by primary, community, secondary and
specialist healthcare services within the NHS. The guideline will include specifically:
● Care in general practice and NHS community care, hospital outpatient, day and
inpatient care (including secure hospitals and tertiary settings), and the interface
between these settings.
● Care in prisons and young offender institutions, and the transition from prison
health services to care in the NHS outside of prison.
This is an NHS guideline. This guideline will comment on the interface with a
range of other settings, services and agencies, such as social care services, educa-
tional services, the criminal justice system, the police, housing and residential care,
and the voluntary sector. The guideline may include recommendations relating to
these settings, services and agencies where the recommendations are relevant to the
prevention, treatment, care and management of antisocial personality disorder.
CLINICAL MANAGEMENT
Areas that will be covered by the guideline:

● The assessment of people with antisocial personality disorder both before and
after diagnosis and the identification of the threshold for intervention.
● Identification of risk factors for adult antisocial personality disorder in children
and young people, including the early identification of child and adolescent
behaviour disorders that are precursors or risk factors for antisocial personality
disorder.
● The full range of treatment and care normally made available by the NHS, includ-
ing health services in prisons and young offender institutions.
● The assessment and management of the risk of self-harm and violent and offend-
ing behaviour in people with diagnosed antisocial personality disorder.
● Psychological and psychosocial interventions, including type, format, frequency,
duration and intensity. Consideration will be given as to which settings are most
appropriate for which intervention. Approaches to be considered will include a
broad range of psychological and psychosocial interventions normally provided in
the NHS including therapeutic communities.
● The appropriate use of pharmacological interventions, including initiation and
duration of treatment, management of side effects and discontinuation. Note that
245
Appendix 1
guideline recommendations will normally fall within licensed indications;

exceptionally, and only where clearly supported by evidence, use outside a
licensed indication may be recommended. The guideline will assume that
prescribers will use a drug’s Summary of Product Characteristics to inform their
decisions for individual patients. Nevertheless, where pharmacological interven-
tions are commonly utilised off-licence in treatment strategies for people with
antisocial personality disorder in the NHS, the evidence underpinning their usage
will be critically evaluated.
● Combined pharmacological and psychological/psychosocial treatments.
● The nature of the therapeutic or other environment in which any interventions
should be delivered.
● Support and supervision systems to facilitate the delivery of effective interven-
tions, including team and individual professional functioning and how they are
influenced by working with this client group.
● Sensitivity to different beliefs and attitudes of different races and cultures, and
issues of social exclusion.
● The role of the family or carers in the treatment and support of people with anti-
social personality disorder (with consideration of choice, consent and help), and
support that may be needed by carers themselves.
● Preventative/protective measures and interventions with children and young
people who are at significant risk of developing adult antisocial personality disor-
der, in particular those with a diagnosis of conduct disorder and young offenders
serving custodial and non-custodial sentences (including educational interven-
tions and interventions with carers/parents).
● The transition from child and adolescent services to adult services.
The guideline development group will take reasonable steps to identify ineffective
interventions and approaches to care. When robust and credible recommendations for
re-positioning the intervention for optimal use, or changing the approach to care to
make more efficient use of resources, can be made, they will be clearly stated. When
the resources released are substantial, consideration will be given to listing such
recommendations in the ‘Key priorities for implementation’ section of the guideline.
AREAS THAT WILL NOT BE COVERED BY THE GUIDELINE
● The guideline will not cover treatments that are not normally available within the
NHS or prison health services.
STATUS
Scope
This is the first draft of the scope, which will be reviewed by the Guidelines Review
Panel and the Institute’s Guidance Executive.
246
Appendix 1
The guideline will incorporate the following relevant technology appraisal

guidance issued by the Institute in collaboration with the Social Care Institute for
Excellence: Parent-training/education programmes in the management of children
with conduct disorders NICE technology appraisal guidance 102 (Published July
2006).
The guideline will also cross refer to relevant clinical guidance23 issued by the
Institute, including:
● Schizophrenia: core interventions in the treatment and management of schizo-
phrenia in primary and secondary care (2002)
● Depression: the management of depression in primary and secondary care (2004)
● Anxiety: management of generalised anxiety disorder and panic disorder (2004)
● Self-harm: the short-term physical and psychological management and secondary
prevention of self-harm in primary and secondary (2004)
● Post-traumatic stress disorder: management of PTSD in adults in primary, second-
ary and community care (2005)
● Obsessive-compulsive disorder: core interventions in the treatment of obsessive-
compulsive disorder and body dysmorphic disorder (2005)
● Violence: the short-term management of disturbed/violent behaviour in in-patient
psychiatric settings and emergency departments (2005)
● Bipolar disorder: the management of bipolar disorder in adults, children and
adolescents, in primary and secondary care (2006)
● Drug misuse: opioid detoxification (2007)
● Drug misuse: psychosocial interventions (2007)
● Attention deficit hyperactivity disorder: diagnosis and management of ADHD in
children, young people and adults (2008)
● Borderline personality disorder: treatment and management (2009).
GUIDELINE
The development of the guideline recommendations will begin in March 2007.
FURTHER INFORMATION
Information on the guideline development process is provided in:

● an overview for stakeholders, the public and the NHS (2006 edition)
● the guidelines manual (2006 edition)
These booklets are available as PDF files from the NICE website
(http://www.nice.org.uk/page.aspx?o⫽guidelinesmanual). Information on the progress
of the guideline will also be available from the website.
23Sincethe Scope was issued some of the guideline titles had changed during development; the titles have
been corrected here to reflect those changes.
247
Appendix 1
Appendix – Referral from the Department of Health
The Department of Health asked the Institute to consider preventative and treatment
interventions for antisocial personality disorder in education, in primary healthcare
and in specialist services including prisons for adults and children and adolescents
and to consider which treatment settings are most appropriate for which intervention.
248
Appendix 2
APPENDIX 2:
DECLARATIONS OF INTERESTS BY GDG MEMBERS
With a range of practical experience relevant to antisocial personality disorder in the

GDG, members were appointed because of their understanding and expertise in
healthcare for people with antisocial personality disorder and support for their fami-
lies and carers, including: scientific issues; health research; the delivery and receipt
of healthcare, along with the work of the healthcare industry; and the role of profes-
sional organisations and organisations for people with antisocial personality disorder
and their families and carers.
To minimise and manage any potential conflicts of interest, and to avoid any
public concern that commercial or other financial interests have affected the work of
the GDG and influenced guidance, members of the GDG must declare as a matter of
public record any interests held by themselves or their families which fall under spec-
ified categories (see below). These categories include any relationships they have
with the healthcare industries, professional organisations and organisations for people
with antisocial personality disorder and their families and carers.
Individuals invited to join the GDG were asked to declare their interests before
being appointed. To allow the management of any potential conflicts of interest that
might arise during the development of the guideline, GDG members were also asked
to declare their interests at each GDG meeting throughout the guideline development
process. The interests of all the members of the GDG are listed below, including inter-
ests declared prior to appointment and during the guideline development process.
Categories of interest
● Paid employment
● Personal pecuniary interest: financial payments or other benefits from either the
manufacturer or the owner of the product or service under consideration in this
guideline, or the industry or sector from which the product or service comes. This
includes holding a directorship, or other paid position; carrying out consultancy
or fee paid work; having shareholdings or other beneficial interests; receiving
expenses and hospitality over and above what would be reasonably expected to
attend meetings and conferences.
● Personal family interest: financial payments or other benefits from the health-
care industry that were received by a member of your family.
● Non-personal pecuniary interest: financial payments or other benefits received
by the GDG member’s organisation or department, but where the GDG member
has not personally received payment, including fellowships and other support
provided by the healthcare industry. This includes a grant or fellowship or other
249
Appendix 2
payment to sponsor a post, or contribute to the running costs of the department;

commissioning of research or other work; contracts with, or grants from, NICE.
● Personal non-pecuniary interest: these include, but are not limited to, clear
opinions or public statements you have made about antisocial personality disor-
der, holding office in a professional organisation or advocacy group with a direct
interest in antisocial personality disorder, other reputational risks relevant to anti-
social personality disorder.
Declarations of interest
Professor Conor Duggan - Chair, Guideline Development Group
Employment Professor of Forensic Mental Health, University
of Nottingham
Honorary Consultant Psychiatrist,
Nottinghamshire Healthcare Trust
Personal pecuniary interest None
Personal family interest None
Non-personal pecuniary Department of Health grant to Nottinghamshire
interest Healthcare NHS Trust to employ senior academ-
ics and research worker to further research into
personality disorder; £170,000 per annum
Research grants:
2007–2010 Duggan, Ferriter, Huband, Smailagic
& Dennis. Partnership bid between the Cochrane
Developmental, Psychosocial and Learning
Problems Group and Nottinghamshire
Healthcare NHS Trust. National Institute for
Health Research, £408,594.
2007 Duggan, Ferriter, Huband & Smailagic. A
review of reviews on sexual and domestic
violence. CSIP; £45,000
2004–2006 Systematic review into the treatment
of personality disorder. National Forensic R & D
Committee; £100,000
IMPALOX study with Peter Tyrer
Involved in translational research at
Collaboration for Leadership in Applied Health
Research and Care funded by National Institute
for Health Research
Continued
250
Appendix 2
Declarations of interest (Continued)

Personal non-pecuniary Fellow of Royal College of Psychiatrists.
interest Advisory member of Home Office Expert
Advisory Panel.
Dr Gwen Adshead
Employment Consultant Forensic Psychotherapist, Broadmoor
Hospital, West London Mental Health NHS
Trust
Personal pecuniary interest Lecture on personality disorder at an educational
conference organised by World Forum for
Mental Health; £200
2004–2004 Funding from the Wellcome Trust to
study moral reasoning in men with antisocial
Non-personal pecuniary None
interest
Personal non-pecuniary None
interest
Professor Jeremy Coid
Employment Professor of Forensic Psychiatry, Wolfson
Institute of Preventive Medicine, Queen Mary,
University of London
Non-personal pecuniary Ongoing: funding from Ministry of Justice to
interest investigate risk
2008 National Institute for Health Research
interest
Mr Neil Connelly – Representing the interests of service users and carers
Continued
251
Appendix 2

interest
interest
Mr Colin Dearden
Employment Deputy Chief Probation Officer, Lancashire
Probation Service
interest
interest
Dr Brian Ferguson
Employment Consultant Psychiatrist and Clinical Director of
Specialist Services, Lincolnshire Partnership
NHS Foundation Trust
Personal pecuniary interest 2006 Attended European College of
Neuropsychopharmacology Congress in Paris as
a guest of Janssen-Cilag, who paid for registra-
tion, accommodation, meals and travel
Non-personal pecuniary Deputy lead for East Midlands Mental Health
interest Research Hub, which has adopted a number of
research projects including one sponsored by
Janssen-Cilag
Involved in translational research at
Collaboration for Leadership in Applied Health
Research and Care funded by National Institute
for Health Research
Personal non-pecuniary In discussion with Servier Research and
interest Development Ltd in respect of a joint pharma-
ceutical trial in the treatment of major depres-
sion, with the role of Deputy Head for the East
Midlands Research Hub
Continued
252
Appendix 2

Professor Peter Fonagy
Employment Freud Memorial Professor of Psychoanalysis,
University College London
Head of Research Department of Clinical,
Educational and Health Psychology, University
College London
Chief Executive, Anna Freud Centre, London
Non-personal pecuniary Research grants:
interest 2008–2012 With Stephen Pilling. Randomised
controlled trial to evaluate multi-systemic ther-
apy. Department of Health; £1 m
2006–2009 Danya Glaser, Peter Fonagy & Rob
Senior. Framework for Recognition, Assessment
and Management of Emotional Abuse
(FRAMEA). Department of Education and
Skills; £325,000
2005–2007 Peter Fonagy & Mary Target.
Randomised controlled trial of parent-infant
psychotherapy. Big Lottery Fund; £206,000
2005–2008 Peter Fonagy & Stewart Twemlow.
Building Peaceful Communities Project. FHL
Foundation, Inc.; US$10,000
2005–2008 Mike Crawford & Peter Fonagy.
Learning the Lessons: an evaluation of pilot
community services for adults with personality
disorder; NHS Service Delivery Organisation,
£286,076
2005–2008 Janet Feigen-Baum & Peter Fonagy.
Mellow Parenting Programme to Support the
Parenting of Mothers with Personality Disorder.
Department for Education and Skills; £204,336
2002–2006 Randomised controlled trial of a
nursery-based early intervention service; Diana,
Princess of Wales Memorial Fund, £48,000
Continued
253
Appendix 2

interest
Dr Savas Hadjipavlou
Employment Programme Director, The Dangerous and Severe
Personality Disorder (DSPD) Programme,
Ministry of Justice
Personal pecuniary None
interest
interest
Personal non-pecuniary Represented the DSPD Programme at various
interest conferences
Professor Eddie Kane
Employment Director, Personality Disorder Institute,
University of Nottingham
interest
interest
Professor Anthony Maden
Employment Professor of Forensic Psychiatry, Imperial
College; Honorary Consultant, West London
Mental Health NHS Trust
Personal pecuniary interest Lecture to Trent study day, sponsored by
Janssen Cilag; £1,000.
Clinical director of a service for Dangerous and
Severe Personality Disorder
interest
Continued
254
Appendix 2

Personal non-pecuniary Have advised Janssen-Cilag on planning an
interest audit of Risperdal use in mental illness in high
security hospitals; no payment agreed
Have advocated mental health law reform to
remove the ‘treatability’ clause from psycho-
pathic disorder
Professor James McGuire
Employment Professor of Forensic Clinical Psychology,
University of Liverpool
Honorary Consultant Clinical Psychologist,
Mersey Care NHS Trust
Non-personal pecuniary 2006–2009 With Prof. J. Hill, Dr. R. Nathan,
interest Prof. P. Kinderman, Dr. G. Lancaster and Prof.
M. Knapp. National R&D Programme in
Forensic Mental Health: Evaluation of a
Community Risk Assessment and Management
Service. Department of Health; £149,857
2006–2009 With Prof. P. Salmon, Clinical
Psychology Fellow in Addictions. Windsor
Clinic, Mersey Care NHS Trust, £160,948
2005–2007 With Prof. C. R. Hollin, Dr. E. J.
Palmer, R. Hatcher & C. Bilby. Northern Ireland
Office: Evaluation of Offending Behaviour
Programmes. Joint project with the University of
Leicester; £79,345
2008–2009 With Drs. R. Whittington, W. Barr &
M. Leitner: Update and extensions and risk
assessment and intervention systematic review.
Department of Health, National Institute for
Health Research, Research for Patient Benefit
Programme; £159,133
2008–2009 Evaluation of a Stepped Care
Psychology Service in HM Prison Liverpool.
Mersey Care NHS Trust; £30,000
Continued
255
Appendix 2

Personal non-pecuniary Until May 2008 member of the Board of
interest Management, Resettle/CRACMS (Community
Risk Assessment and Case Management
Service), a multi-agency service being
established in North West England. Jointly
funded by the Home Office and the Department
of Health
Ms Carol Rooney
Employment Deputy Director of Nursing, St Andrews
Healthcare
interest
interest
Dr Nat Wright
Employment Clinical Director for Substance Misuse, HM
Prison Leeds
Personal pecuniary interest GP adviser Department of Health, Prison Health
Unit; funds 50% of salary
interest
interest
National Collaborating Centre for Mental Health
Dr Stephen Pilling – Facilitator, Guideline Development Group

Employment Joint Director, National Collaborating Centre
for Mental Health
Director, Centre for Outcomes Research and
Effectiveness, University College London
Continued
256
Appendix 2
Personal pecuniary interest In receipt of funding from NICE to develop

clinical guidelines
Non-personal pecuniary interest 2008–2012 Randomised controlled trial to
evaluate multi-systemic therapy. Principal
investigator: Professor Peter Fonagy.
Department of Health; £1 m
Personal non-pecuniary interest None
Ms Amy Brown
Employment Research Assistant (2007), National
Collaborating Centre for Mental Health
Non-personal pecuniary interest None
Mr Alan Duncan
Employment Systematic Reviewer, National Collaborating
Centre for Mental Health
Mr Matthew Dyer
Employment Health Economist, National Collaborating
Continued
257
Appendix 2
Ms Esther Flanagan
Employment Project Manager (2008–2009), National
Mr Ryan Li
Employment Project Manager (2008), National
Dr Ifigeneia Mavranezouli
Employment Health Economist, National Collaborating
Dr Nick Meader
Employment Systematic Reviewer, National Collaborating
Continued
258
Appendix 2
Dr Catherine Pettinari
Employment Senior Project Centre Manager, National
Ms Peny Retsa
Employment Health Economist (2007–2008), National
Ms Maria Rizzo
Employment Research Assistant (2007–2008), National
Ms Sarah Stockton
Employment Information Scientist, National Collaborating
Continued
259
Appendix 2
Dr Clare Taylor
Employment Editor, National Collaborating Centre for
Mental Health
260
Appendix 3
APPENDIX 3:
SPECIAL ADVISERS TO THE GUIDELINE
DEVELOPMENT GROUP
Name Employed by
Dennis Lines Carer representative for people with personality disorders
John Livesley University of British Columbia, Canada
261
Appendix 4
APPENDIX 4:
STAKEHOLDERS WHO RESPONDED TO EARLY
REQUESTS FOR EVIDENCE
None
262
Appendix 5
APPENDIX 5:
STAKEHOLDERS AND EXPERTS WHO
SUBMITTED COMMENTS IN RESPONSE TO THE
CONSULTATION DRAFT OF THE GUIDELINE
STAKEHOLDERS
Alder Hey Children’s NHS Foundation Trust

Association for Cognitive Analytic (ACAT) Therapy
British Association of Art Therapists
British Paediatric Mental Health Group
Cassel Hospital
College of Occupational Therapists
Department of Health
Greater Manchester West Mental Health NHS Foundation Trust
Hampshire Partnership NHS Trust
NHS Direct
Nottinghamshire Healthcare NHS Trust
Oxleas NHS Foundation Trust and the Douglass House Project
Partnerships in Care
Royal College of Nursing
Sainsbury Centre for Mental Health
Sussex Partnership NHS Trust
Tavistock and Portman Foundation Trust
University of Liverpool
EXPERTS
Professor Jay Belsky

Dr Mike Crawford
Professor Mark Dadds
Dr Caroline Logan
Professor Chris Patrick
263
Appendix 6
APPENDIX 6:
RESEARCHERS CONTACTED TO REQUEST
INFORMATION ABOUT UNPUBLISHED OR
SOON-TO-BE PUBLISHED STUDIES
Dr Geoffrey Baruch
Professor Charlie Brooker
Professor Avshalom Caspi
Dr Patricia Chamberlain
Professor John F. Clarkin
Professor Kate Davidson
Professor Tom Fahy
Professor John G. Gunderson, MD
Professor Scott Henggeler
Professor Jonathan Hill
Professor Sheilagh Hodgins
Professor Alan Kazdin
Dr Niklas Langstrom
Professor Terrie Moffitt
Professor Roger Mulder
Professor David Olds
Professor Paul Pilkonis
Professor Michael H. Stone
Professor Brian Thomas-Peter
Professor Peter Tyrer
Professor Richard Tremblay
Professor Christopher Webster
Professor John Weisz
Professor Stephen Wong
264
Appendix 7
APPENDIX 7:
ANALYTIC FRAMEWORK AND CLINICAL
QUESTIONS
Topic area Key question(s)
1 Assessment and referral 1a. What is the threshold for intervening to
treat problems associated with antisocial
personality disorder?
1b. What is the threshold for intervening to
treat symptoms associated with antisocial
1c. What is the threshold for intervening to
treat antisocial personality disorder?
1d. What is the threshold at which other
treatment and care should be modified
because of antisocial personality disorder?
1e. What is the threshold for referral to
another service or setting?
1f. When is a formal diagnosis of antisocial
personality disorder needed/when does a diag-
nosis of antisocial personality disorder
improve outcomes?
1g. What are the harms of diagnosis?
1h. What is the threshold for risk assessment?
2 Interventions for adults 2. What interventions for people with
with antisocial antisocial personality disorder improve
personality disorder outcomes?
3 Treatment of comorbid 3. For people with antisocial personality
disorders disorder with comorbid disorders, does
treatment of comorbid disorders improve
outcomes?
4 Interventions for 4. For people with antisocial personality
offending behaviour disorder, do interventions for offending
behaviour improve outcomes?
Continued
265
Appendix 7
Topic area Key question(s)

5 Structures for the delivery 5a. What service structures for the
of care and management management of ongoing long-term care and
of people with antisocial the delivery of interventions for people with
personality disorder antisocial personality disorder deliver the
best outcomes?
5b. What organisational structures and
processes to support professionals and staff
caring for and managing people with antiso-
cial personality disorder deliver the best
outcomes?
6 Risk assessment and 6. For people with antisocial personality
management for adults disorder, does formal risk assessment and
with antisocial management improve outcomes and reduce
personality disorder harm to others?
7 Early intervention in 7a. Are there early interventions for young
children and adolescents at-risk children that are effective at preventing
to prevent antisocial antisocial personality disorder?
7b. Are interventions with children and
adolescents with conduct disorder effective at
preventing antisocial personality disorder?
CLINICAL QUESTIONS
1.1 Assessment and referral
1.1.1 What is the threshold for intervening to treat problems associated with
antisocial personality disorder?
1.1.2 What is the threshold for intervening to treat symptoms associated with
1.1.3 What is the threshold for intervening to treat antisocial personality disorder?
1.1.4 What is the threshold at which other treatment and care should be modified
because of antisocial personality disorder?
1.1.5 What is the threshold for referral to another service or setting?
1.1.6 When is a formal diagnosis of antisocial personality disorder needed/when
does a diagnosis of antisocial personality disorder improve outcomes?
1.1.7 What are the harms of diagnosis?
1.1.8 What is the threshold for risk assessment?
266
Appendix 7
2. What interventions for people with antisocial personality disorder

improve outcomes?
2.1 Interventions in primary care for problems associated with antisocial

2.1.1 What identifies people who have the potential to benefit from, and meet the
threshold for, primary care interventions for antisocial personality disorder
related problems?
2.1.2 What interventions to address problems and behaviour associated with
antisocial personality disorder, or to promote harm avoidance, improve
outcomes?
2.1.3 For each of these interventions, what factors favour and contraindicate referral?
2.1.4 What harms are associated with interventions to address problems and
behaviour associated with antisocial personality disorder?
2.1.5 Where people with antisocial personality disorder have problems that are
primarily social, are there non-healthcare services that improve outcomes?
2.1.6 What harms to people with antisocial personality disorder are associated
with their use of non-healthcare services?
2.2 Secondary care mental health interventions to treat ‘symptoms’ of

threshold for, interventions to treat antisocial personality disorder symptoms?
2.2.2 What interventions are effective at treating symptoms of antisocial person-
ality disorder?
2.2.3 For each of these interventions, what factors favour and contraindicate
referral?
2.2.4 What are the harms of interventions to treat symptoms of antisocial person-
ality disorder?
2.3 Interventions to treat antisocial personality disorder in tertiary care /

specialist services
threshold for, interventions to treat antisocial personality disorder?
2.3.2 What interventions are effective at treating antisocial personality disorder?
2.3.3 For each of these interventions, what factors favour and contraindicate
referral?
2.3.4 What are the harms of interventions to treat antisocial personality disorder?
2.4 The therapeutic environment

2.4.1 For people with antisocial personality disorder, what features of the envi-
ronment in which interventions are delivered improve outcomes?
267
Appendix 7
2.4.1 For people with antisocial personality disorder, what features of the envi-
ronment in which interventions are delivered cause harm?
3. For people with antisocial personality disorder with comorbid

disorders, does treatment of comorbid disorders improve
outcomes?
3.1 Assessment for people with antisocial personality disorder and comorbid
disorders
3.1.1 Where people with antisocial personality disorder have multiple comor-
bidities, what disorders/problems should be treated first?
3.1.2 Should people with antisocial personality disorder who have been treated
for comorbid disorders be referred for assessment and treatment of anti-
social personality disorder or antisocial personality disorder symptoms?
3.2 Interventions for people with antisocial personality disorder who have
comorbid alcohol problems or dependence
3.2.1 What identifies people with antisocial personality disorder who have the
potential to benefit from, and meet the threshold for, interventions for alco-
hol problems or dependence?
3.2.2 What interventions are effective at treating alcohol problems or depend-
ence in people with antisocial personality disorder?
3.2.2a Are interventions for alcohol problems or dependence less effective for
people with antisocial personality disorder?
3.2.2b How should interventions for alcohol problems or dependence be adapted
for people with antisocial personality disorder?
3.2.3 For people with antisocial personality disorder, what are the harms of treat-
ing alcohol problems or dependence?
comorbid drug misuse or dependence
potential to benefit from, and meet the threshold for, interventions for drug
misuse or dependence?
3.3.2 What interventions are effective at treating drug misuse or dependence in
3.3.2a Are interventions for drug misuse or dependence less effective for people
with antisocial personality disorder?
3.3.2b How should interventions for drug misuse or dependence be adapted for
ing drug misuse or dependence?
268
Appendix 7
comorbid depression or anxiety
potential to benefit from, and meet the threshold for, interventions for
depression or anxiety?
3.4.2 What interventions are effective at treating depression or anxiety in people
ing depression or anxiety?
comorbid personality disorders
comorbid personality disorders?
3.5.2 What interventions are effective at treating comorbid personality disorders
in people with antisocial personality disorder?
ing comorbid personality disorders?
4. For people with antisocial personality disorder, do interventions for

offending behaviour improve outcomes?
4.1 Could any interventions for offending behaviour be used as interventions

to treat people with antisocial personality disorder in a healthcare setting?
4.1.1 What interventions are effective at reducing re-offending in the general
offender population?
4.1.2 What harms to offenders are associated with interventions to reduce
offending behaviour?
4.1.3 In offender populations, what factors can be used as proxy indicators of
antisocial personality disorder and validate extrapolation to people with
offending behaviour?
4.1.5 What interventions for offenders improve outcomes for people with antiso-
cial personality disorder or offenders with proxy indicators of antisocial
4.1.5a For each of these interventions, does the effectiveness differ for offenders
with antisocial personality disorder compared with the general offender
population?
4.1.5b For each of these interventions, what factors favour and contraindicate
referral?
269
Appendix 7
4.1.6 What harms to people with antisocial personality disorder are associated
with interventions to reduce offending behaviour?
5a. What service structures for the management of ongoing long-term

care and the delivery of interventions for people with antisocial
personality disorder deliver the best outcomes?
5.1.1 What identifies people with antisocial personality disorder who need long-
term care and support through and beyond treatment interventions?
5.1.2 What service structures for delivering interventions and providing ongoing
long-term care and support for people with antisocial personality disorder
improve outcomes?
5.1.3 What harms are associated with structures for providing care for people
5.1.4 What are the support needs of carers/people (including children) who live
with people with antisocial personality disorder?
5.1.5 How can services meet the support needs of carers/people (including chil-
dren) who live with people with antisocial personality disorder?
5.1.6 Does the delivery of care and interventions for the person with antisocial
personality disorder cause harms to carers/the people (including children)
who live with them?
5.1.7 Do the support needs of carers/people (including children) who live with
people with antisocial personality disorder conflict with the needs of the
person with antisocial personality disorder?
5b. What organisational structures and processes to support

professionals and staff caring for and managing people with
antisocial personality disorder deliver the best outcomes?
5.2.1 What are the potential harms to professionals and staff from working with
5.2.1a Do harms to professionals and staff lead to harms to the people with antisocial
personality disorder they care for (for example by undermining treatment)?
5.2.2 How can services address the challenges of providing care for people with
5.2.2a What support for staff including training, consultation/liaison, supervision,
peer support, team-based and collective working is associated with improved
outcomes?
5.2.2b What leadership and management interventions (including clarity of roles
and purpose, taking responsibility, case loads) are associated with improved
outcomes?
5.2.3 What are the harms of measures to address the challenges of providing care
for people with antisocial personality disorder?
270
Appendix 7
5.2.4 Is there a conflict between what delivers better outcomes for people with
antisocial personality disorder and what delivers better outcomes for
professionals and staff?
5.2.5 Is there evidence on what ethos adopted by a service is most likely to
deliver better outcomes?
6. For people with antisocial personality disorder, does formal risk

assessment and management improve outcomes and reduce harm to
others?
6.1 Risk assessment

6.1.1 What is the threshold for formal risk assessment?
6.1.2 What instruments and tools predict risk in people with antisocial personal-
ity disorder?
6.1.2a. What features of a risk assessment process make it more effective at
predicting/improving outcomes?
6.1.3 What are the harms of risk assessment?
6.2 Risk management

6.2.1 What is the threshold for structured risk management?
6.2.2 Does structured risk management improve outcomes?
6.2.2a What are the essential features of an effective risk management plan?
6.2.3 What are the harms of structured risk management?
6.2.4 What is the threshold for limiting an individual’s freedom because of risk?
6.2.5 Does limiting an individual’s freedom improve outcomes?
6.2.6 What are the harms of limiting an individual’s freedom?
7a. Are there early interventions for young at risk children that are
effective at preventing antisocial personality disorder?
7.1 Early interventions for young children at risk of developing antisocial

personality disorder prior to the development of behavioural symptoms
7.1.1 What identifies children at risk of developing antisocial personality disor-
der before they develop behavioural disorders (with particular reference to
developmental, psychosocial and family factors)?
7.1.1a What are key modifiable risk factors that can be targeted by interventions?
7.1.1b How can children who would benefit from interventions be identified?
7.1.2 For children who do not have behavioural disorders, what are the harms of
early identification of risks for antisocial personality disorder (with partic-
ular consideration of harm from stigma/labelling)?
7.1.3 What proportion of young children with risk factors for antisocial person-
ality disorder will go on to develop conduct disorder?
271
Appendix 7
7.1.3a Where children have risk factors for antisocial personality disorder, what
is the likelihood that they will go on to develop antisocial personality
disorder?
7.1.4 What early interventions improve intermediate outcomes?
7.1.4a Following early intervention, what proportion of young children with risk
factors for antisocial personality disorder will go on to develop conduct
disorder and meet criteria for interventions for conduct disorder?
7.1.4b What early interventions prevent antisocial personality disorder?
7.1.5 What are the harms of early interventions (with particular consideration of
harm from stigma/labelling)?
7.1.6 For children with risk factors for antisocial personality disorder who
develop conduct disorder following early intervention, does early interven-
tion make them more susceptible to interventions for conduct disorder?
7b. Are interventions with children and adolescents with conduct

disorder effective at preventing antisocial personality disorder?
7.2 Interventions for children and young people with conduct disorder
7.2.1 What identifies young people who could benefit from interventions for
conduct disorder?
7.2.2 What are the harms of identification of conduct disorder (with particular
consideration of harm from stigma/labelling)?
7.2.3 What is the likelihood that a young person with conduct disorder will
convert to antisocial personality disorder?
7.2.3a What other factors are most predictive of conversion to antisocial person-
ality disorder?
7.2.4 What interventions for conduct disorder improve intermediate outcomes?
7.2.4a What interventions for conduct disorder prevent antisocial personality
disorder?
7.2.5 What are the harms of treatment for conduct disorder?
7.2.6 For young people in contact with services because of conduct disorder,
how should the transition to adult services be managed to maintain consis-
tency of care and interventions, promote beneficial treatment outcomes and
minimise harms?
272
Analytic framework 1: Settings, assessment and referral
Primary care / GP Secondary specialist Tertiary 'super Other services Criminal

A&E mental health services specialist' services (including social care, justice
(including forensic services, housing, drug and system
secure settings, alcohol services)
DSPD services)
People presenting People referred to Direct referral into People in other Offenders in the
in primary care due secondary tertiary services services with criminal justice
to problems, specialist mental from the criminal problem system
comorbid disorders health services for justice system behaviours
or physical treatment of following serious indicative of /
symptoms with comorbid disorders violent offending raising concern
behaviour and/or whose presentation about antisocial
problems indicative or behaviour gives personality disorder
of / raising concern rise to concern (aggression,
about antisocial about antisocial violence, offending
personality disorder personality disorder etc)
People presenting
in A&E (possibly
repeatedly) due to
injuries caused by
behaviour
indicative of
possible antisocial
(violence,
offending, risk
taking behaviour,
drug/alcohol use or
self-harm with
other indicators of
antisocial personality
disorder)
Presentation in primary care or A&E of partner or child indicative of abuse (or neglect in the case of a child) or allegation of abuse/neglect raising concern
about violent behaviour / antisocial personality disorder in family member/ cohabitee of the person presenting
273
Appendix 7
Analytic framework 2: Interventions for adults with antisocial personality disorder
274
Appendix 7
2.
Referral / redirection to Offending [any

non-NHS/non-healthcare servcies
Non-healthcare
See detailed analytic
accepted measure of
needs addressed:
framework on assessement Problems primarily offending including:
2.1.4 ? Housing
and referral 'social' - housing etc recall and antisocial
2.1.5 ? Employment personality disorder
? Social care needs behaviours - violence,
Harms
antisocial behaviour,
Clinical Interventions to address problems aggression, harm to
Measures of antisocial
population personality disorder others etc]
People with antisocial
problems and/or Secondary outcomes
Adults 2.1.1 personality disorder 2.1.2 behaviour:
with antisocial treated in primary care ? Anger
> Harm to self
> Primary care interventions
2.1.3
personality ? Antisocial > Mental state
disorder > Promoting harm avoidance behaviour (depression,
Assessment Harms
Assessment& Interventions for antisocial anxiety)
referral People with antisocial personality disorder 'symptoms' Measures of antisocial > Substance use
Adults personality disorder (drugs, alcohol)
with a 2.2.2 symptoms:
2.2.1 treated in secondary care
high PCL- 2.2.3 ? Impulsivity
mental health services > Psychotherapy
R score ? Aggression
> Pharmacotherapy
Harms
Interventions for antisocial
People with antisocial personality disorder
2.3.1 personality disorder 2.3.2 2.3.3

treated in tertiary /
2.3.4
specialist services > Psychotherapy
> Pharmacotherapy Harms
> Combined interventions
> Complex interventions Therapeutic environment for
> Therapeutic communities the delivery of interventions
2.4.1
Harms 2.4.2
Analytic framework 3: Interventions to treat comorbid disorders in people with antisocial personality disorder
3.
See detailed
analytic
Interventions to treat drug
framework on
assessement People with antisocial misuse or dependence Treatment outcomes Offending [any
and referral personality disorder who for drug misuse / accepted measure of
3.2.1 3.2.2
have comorbid drug dependence: offending including:
misuse or dependence 3.2.3
abstinence recall and antisocial
Clinical Harms personality disorder
population behaviours - violence,
Interventions to treat problem Treatment outcomes antisocial behaviour,
Adults drinking/alcohol dependence aggression, harm to
People with antisocial for alcohol problems /
with antisocial
personality disorder who dependence: alcohol others etc]
personality 3.3.1 3.3.2
disorder have comorbid alcohol consumption / Secondary outcomes
Assessment problems / dependence 3.3.3
abstinence, problem > Harm to self
Adults Assessment & Harms drinking > Mental state
with a referral (depression,
high score Interventions to treat anxiety)
on the PCL-R 3.1.1 People with antisocial depression and anxiety, PTSD Treatment outcomes > Substance use
personality disorder who for Axis I disorders: (drugs, alcohol)
3.4.1 3.4.2
have comorbid Axis I mental state,
disorders (depression, 3.4.3
depression, anxiety
anxiety, PTSD) Harms
[Offenders]
Interventions to treat other
personality disorders
People with antisocial Treatment outcomes
3.5.1 personality disorder who 3.5.2 for comorbid
have comorbid 3.5.3 personality disorders
personality disorders
Harms
3.1.2
275
Appendix 7
276
Appendix 7
Analytic framework 4: Interventions for offending behaviour
4.
Clinical See detailed analytic framework
4a. Offending [any
population on assessement and referral accepted measure of
Adults with offending including:
antisocial Offenders with antisocial recall and antisocial
personality personality disorder personality disorder
4.1.4 4.1.5
disorder Assessment & diagnosis behaviours - violence,
Adults with referral Interventions for 4.1.6 antisocial behaviour,
a high PCL-R 4.1.3 offending behaviour aggression, harm to
score [Include coercive interventions] others etc]
General offender Harms
Secondary outcomes
[Offenders] population (no antisocial 4.1.1 > Harm to self
4.1.2 > Mental state
diagnosis but possible
(depression,
antisocial
anxiety)
personality disorder) Harms > Substance use
(drugs, alcohol)
Analytic framework 5: Structures for the management of care and the delivery of interventions for people with antisocial
5a.
Clinical population Structures for the care and
management of people with Primary outcomes for the person with
People receiving
antisocial personality disorder antisocial personality disorder
Adults with 5.1.1 care and treatment
antisocial from services who 5.1.2 > Offending (includes harm to others)
personality meet the threshold > Harm to self
Assessment & > Case management
disorder for antisocial Secondary staff / service outcomes
referral > Assertive outreach
personality disorder to Staff outcomes
Adults > Community outreach
be considered in their > Staff morale & anxiety
with a > Team based /
clincial management multidisciplinary working > Staff turnover & burnout
high PCL-R See separate > Staff competence
score > Other approaches
analytic
Efficiency of care
frameworks
> Risk assessment > Drop out rates / retention in services /
Family and carers and management loss of contact wiith services
of people with 5.1.4 > Service user engagement & satisfaction
antisocial personality > People with antisocial personality
disorder disorder not excluded
5.1.5 5.1.3
> More skilled / better trained staff
> More therapeutic approach
> Risk management outcomes
Harms
Communication and management
> Better communication / team working
> Greater staff clarity of roles and
understanding of purpose
5.1.6
> Appropriate relationships with service
users
Family / carer outcomes
Harms
5.1.7 > Abuse / harm to family / carers
> Family / carer stress
> For children: Develomental /
psychosocial risk factors for
277
Appendix 7
278
Analytic framework 6: Organisational structures and processes to support professionals and staff caring for and managing
Appendix 7
people with antisocial personality disorder
5b.
Organisational structures and Primary outcomes for the person with

processes to support the antisocial personality disorder
Population delivery and management > Offending (includes harm to others)
of care for people with antisocial > Harm to self
Organisation / personality disorder Secondary staff / service outcomes
service providing Staff outcomes
Professionals and 5.2.2 5.2.4
care and/or > Staff morale & anxiety
staff working with
interventions for > Support and training for staff / > Staff turnover & burnout
people with antisocial people with antisocial 5.2.3
personality disorder professionals > Staff competence
5.2.1 personality disorder > Leadership and management Efficiency of care
> Risk assessment and Harms > Drop out rates / retention in services /
Harms mangement loss of contact wiith services
> Service user engagement & satisfaction
> People with antisocial personality disorder
> More skilled / better trained staff
Organisational ethos > More therapeutic approach
5.2.5 > Risk management outcomes
Communication and management
> Better communication / team working
> Greater staff clarity of roles and
understanding of purpose
> Appropriate relationships with service
users
Analytic framework 7: Risk assessment and management for adults with antisocial personality disorder
6.
6.1.2
3
Clinical
population Formal risk Formal risk
assessment + management using
Adults with structured risk structured risk Offending
antisocial assessment management plan
personality Potential risk of harm instruments / tools Risk assessment Harm to others
Assessment > If manged in the
disorder 6.1.1 to others or self 6.2.1
5 identifies risk 6.2.2
6
& referral community: harm
identified. meeting the
Adults threshold for risk to family members/
with a 6.1.3
4 6.2.3
7 carers, harm to
management.
high PCL-R members of the
score public
Harms of risk Harms of risk > In inpatient
assessment management settings: harm to
staff, harm to
other patients
Risk assessment
6.2.4 identifies high risk 6.2.5 Harm to self
and patient admitted
6.2.6
into secure setting
[or retained in
Harms
secure setting].
279
Appendix 7
Analytic framework 8: Early intervention in children and adolescents to prevent antisocial personality disorder
280
A
7a.
7.1.4 7.1.4a
Appendix 7
Intermediate Primary outcomes

Children with risk outcomes:
factors for antisocial Early interventions > Development of
Adult outcomes
personality disorder but (health and social care) behaviour problems
who have not indicating conversion
> Antecendents of
developed conduct to antisocial
antisocial personality
7.1.1 disorder [/other 7.1.5 7.1.5b personality disorder:
Clinical
disorder (conduct
behavioural disorder, offending,
population antecedents of 7.1.6 > antisocial
delinquency,
7.1.2 antisocial personality disorder
antisocial behaviour
personality disorder] diagnosis
> Reduction in risk
Children and > Measures of adult
Harms factors for antisocial
adolescents at offending &
risk of antisocial
antisocial
personality disorder 7.3.1 behaviour
Harms > Measures of
7.1.4a
antisocial
personality traits
> PCL-R
7.1.6 7.2.3
Intermediate
outcomes:
> Outcome measures 7.2.4a
Treatment of conduct for treatment of
Children with conduct disorder
conduct disorder disorder
[/other behavioural 7.2.6a
7.2.1 Assessment & [/other behavioural antecedents of
7.2.4
referral antecedents of antisocial personality
antisocial > Parental disorder]
personality disorder] interventions / > Measures of Young
parent training 7.2.5 juvenile offending,
7.2.2 people
> Interventions delinquency & with
with the child antisocial behaviour Referral to
conduct
Harms adult
disorder
Harms services
referred
to adult
7b.
services
Appendix 8
APPENDIX 8:
SEARCH STRATEGIES FOR THE IDENTIFICATION
OF CLINICAL STUDIES
1. General search strategies
a. MEDLINE, EMBASE, PsycINFO, CINAHL – Ovid interface
1 (antisocial personality disorder$ or dissocial personality disorder or psychopa-

thy).sh,id.
2 (apd$1.tw. and (asocial$ or anti social$ or antisocial$ or character$ or dissocial$
or dis social$ or person$).mp.) or aspd$1.tw.
3 ((asocial$ or antisocial$ or anti social$ or dissocial$ or dis social$) adj3 (charac-
ter$ or difficult$ or disorder$ or dysfunction$ or PD or person$)).tw. or ((asocial$
or antisocial$ or anti social$ or dissocial$ or dis social$) and personalit$).tw,hw.
4 neuropsychopath$ or psychopath$3 or psycho path$3 or sociopath$ or socio
path$).tw.
5 (DSM and (axis and II)).mp.
6 (multiple personality disorder$ or personality disorder$).sh,id.
7 (personalit$ adj2 (disorder$ or dysfunction$)).tw.
8 or/1–7
b. Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews

of Effects, Cochrane Central Register of Controlled Trials – Wiley Interscience
interface
1 MeSH descriptor Antisocial Personality Disorder, this term only

2 (apd* and (asocial* or anti next social* or antisocial* or character* or dissocial*
or dis next social* or person*)) or aspd:ti,ab,kw
3 (asocial* or antisocial* or anti next social* or dissocial* or dis next social*)
near/3 (character* or difficult* or disorder* or dysfunction* or PD or
person*):ti,ab,kw or (asocial* or antisocial* or anti next social* or dissocial* or
dis next social*) and personalit*:ti,ab,kw
4 (neuropsychopath* or psychopath or psychopaths or psychopathia or
psychopathias or psychopathic or psychopathics or psychopathies or psychopa-
thy):ti or (neuropsychopath* or psychopath or psychopaths or psychopathia or
psychopathias or psychopathic or psychopathics or psychopathies or psychopa-
thy):ab
5 (sociopath* or socio near/1 path*):ti or (sociopath* or socio near/1 path*):ab
281
Appendix 8
6 (DSM and (Axis and II)):ti,ab,kw

7 MeSH descriptor Personality Disorders, this term only
8 MeSH descriptor Multiple Personality Disorder, this term only
9 (personalit* near/2 (disorder* or dysfunction*)):ti or (personalit* near/2 (disor-
der* or dysfunction*)):ab
10 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9
2. Systematic review search filters
a. MEDLINE, EMBASE, PsycINFO, CINAHL, AMED, BNI – Ovid interface
1 cochrane library/ or exp literature searching/ or exp literature review/or exp

review literature/ or systematic review/ or meta analysis/ or meta-analysis as
topic/
2 ((systematic or quantitative or methodologic$) adj5 (overview$ or review$)).mp.
3 (metaanaly$ or meta analy$ or metasynthesis or meta synthesis).mp.
4 (research adj (review$ or integration)).mp.
5 reference list$.ab.
6 bibliograph$.ab.
7 published studies.ab.
8 relevant journals.ab.
9 selection criteria.ab.
10 (data adj (extraction or synthesis)).ab.
11 (handsearch$ or ((hand or manual) adj search$)).tw.
12 (mantel haenszel or peto or dersimonian or der simonian).tw.
13 (fixed effect$ or random effect$).tw.
14 ((bids or cochrane or index medicus or isi citation or psyclit or psychlit or
scisearch or science citation or (web adj2 science)) and review$).mp.
15 (systematic$ or meta$).pt. or (literature review or meta analysis or systematic
review).md.
16 (pooled or pooling).tw.
17 or/1-16
3. Randomised controlled trial search filters
a. MEDLINE, EMBASE, PsycINFO, CINAHL, AMED, BNI – Ovid interface
1 exp clinical trials/ or exp clinical trial/ or exp controlled clinical trials/
2 exp crossover procedure/ or exp cross over studies/ or exp crossover design/
3 exp double blind procedure/ or exp double blind method/ or exp double blind
studies/ or exp single blind procedure/ or exp single blind method/ or exp single
blind studies/
4 exp random allocation/ or exp randomization/ or exp random assignment/ or exp
random sample/ or exp random sampling/
282
Appendix 8
5 exp randomized controlled trials/ or exp randomized controlled trial/or random-

ized controlled trials as topic/
6 (clinical adj2 trial$).tw.
7 (crossover or cross over).tw.
8 (((single$ or doubl$ or trebl$ or tripl$) adj5 (blind$ or mask$ or dummy)) or
(singleblind$ or doubleblind$ or trebleblind$)).tw.
9 (placebo$ or random$).mp.
10 (clinical trial$ or random$).pt. or treatment outcome$.md.
11 animals/ not (animals/ and human$.mp.)
12 (animal/ or animals/) not ((animal/ and human/) or (animals/ and humans/))
13 (animal not (animal and human)).po.
14 (or/1-10) not (or/11–13)
Details of additional searches undertaken to support the development of this guide-

line, with special regard to offender, construct and conduct disorder populations, are
available on request.
283
Appendix 9
APPENDIX 9:
CLINICAL STUDY DATA EXTRACTION FORM
Screenshots of bespoke database for extraction of study characteristics.
284
Appendix 9
285

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Antisocial

National Clinical Practice Guideline Number 77

National Collaborating Centre for Mental Health

All rights reserved. No part of this book may be reprinted or reproduced or

British Library Cataloguing-in-Publication Data

developed by National Collaborating Centre for Mental Health

commissioned by National Institute for Health and Clinical Excellence

published by The British Psychological Society

GUIDELINE DEVELOPMENT GROUP MEMBERS 6

5.3 Early interventions 93

8.13 A therapeutic community approach for antisocial

GUIDELINE DEVELOPMENT GROUP MEMBERS

Professor Conor Duggan (Chair, Guideline Development Group)

Dr Stephen Pilling (Facilitator, Guideline Development Group)

Professor Jeremy Coid

Professor Peter Fonagy

Professor Eddie Kane

Professor Anthony Maden

Professor James McGuire

1.1 NATIONAL GUIDELINES

1.1.1 What are clinical practice guidelines?

Clinical practice guidelines are ‘systematically developed statements that assist

1.1.2 Uses and limitations of clinical guidelines

1.1.3 Why develop national guidelines?

NICE generates guidance in a number of different ways, three of which are

1.1.4 The National Collaborating Centre for Mental Health

1.1.5 From national guidelines to local protocols

1.1.6 Auditing the implementation of guidelines

1.2 THE NATIONAL ANTISOCIAL PERSONALITY

1.2.1 Who has developed this guideline?

1.2.2 For whom is this guideline intended?

1.2.3 Specific aims of this guideline

1.2.4 How this guideline is organised

2 ANTISOCIAL PERSONALITY DISORDER

2.2 THE DISORDER

2.2.1 Symptoms, presentation and pattern of disorder

‘a pattern of inappropriate and unmodulated desire to control others, imple-

provided a description of psychopathy. Building on Cleckley’s work, Hare and

2.2.3 Course and prognosis

2.2.4 Prevalence of antisocial personality disorder and related conditions

The prevalence of antisocial personality disorder in the general population varies

professionals. While the incidence of antisocial personality disorder in women may

2.3.1 Gene-environment interactions

As with most psychiatric conditions, antisocial personality disorder is construed as

2.3.2 Biological markers for aggressive behaviour

In addition to these biological factors, there are numerous adverse environmental

2.4 PRESENTATION IN HEALTHCARE AND OTHER SETTINGS

Because people with antisocial personality disorder externalise their difficulties, it is

2.4.1 Treatment attrition

Dropping out of treatment is a particular problem in the treatment of personality

Patient preference, information and consent

2.5 USE OF HEALTH SERVICE RESOURCES AND OTHER COSTS

It is important to recognise that while antisocial personality disorder is associated

2.6 TREATMENT AND MANAGEMENT IN THE NHS

2.6.1 Pharmacological treatments

Although there is no reliable estimate of the use of pharmacological treatments

2.6.2 Psychological treatments

2.6.3 Psychosocial interventions

In the development of treatments for personality disorders the therapeutic community