ARTICLES

Impact of Early Intervention on Psychopathology,

Crime, and Well-Being at Age 25
Kenneth A. Dodge, Ph.D., Karen L. Bierman, Ph.D., John D. Coie, Ph.D., Mark T. Greenberg, Ph.D., John E. Lochman, Ph.D.,
Robert J. McMahon, Ph.D., Ellen E. Pinderhughes, Ph.D., for the Conduct Problems Prevention Research Group

Objective: This randomized controlled trial tested the efficacy one externalizing, internalizing, or substance abuse psychi-
of early intervention to prevent adult psychopathology and atric problem (based on self- or peer interview) at age 25, in
improve well-being in early-starting conduct-problem children. contrast with 59% of those assigned to intervention (odds
ratio=0.59, CI=0.43–0.81; number needed to treat=8). This
Method: Kindergarteners (N=9,594) in three cohorts (1991– pattern also held for self-interviews, peer interviews, scores
1993) at 55 schools in four communities were screened for using an “and” rule for self- and peer reports, and separate
conduct problems, yielding 979 early starters. A total of 891 tests for externalizing problems, internalizing problems, and
(91%) consented (51% African American, 47% European Ameri- substance abuse problems, as well as for each of three
can; 69% boys). Children were randomly assigned by school cohorts, four sites, male participants, female participants,
cluster to a 10-year intervention or control. The intervention African Americans, European Americans, moderate-risk, and
goal was to develop social competencies in children that would high-risk subgroups. Intervention participants also received
carry them throughout life, through social skills training, parent lower severity-weighted violent (standardized estimate=
behavior-management training with home visiting, peer 20.37) and drug (standardized estimate=20.43) crime con-
coaching, reading tutoring, and classroom social-emotional viction scores, lower risky sexual behavior scores (stan-
curricula. Manualization and supervision ensured program dardized estimate=20.24), and higher well-being scores
fidelity. Ninety-eight percent participated during grade 1, and (standardized estimate=0.19).
80% continued through grade 10. At age 25, arrest records were
reviewed (N=817, 92%), and condition-blinded adults psychiat- Conclusions: This study provides evidence for the effi-
rically interviewed participants (N=702; 81% of living participants) cacy of early intervention in preventing adult psychopathol-
and a peer (N=535) knowledgeable about the participant. ogy among high-risk early-starting conduct-problem
children.
Results: Intent-to-treat logistic regression analyses indicated
that 69% of participants in the control arm displayed at least Am J Psychiatry 2014; AiA:1–12; doi: 10.1176/appi.ajp.2014.13060786

A well-replicated finding in developmental psychopathology advocate for incarceration (10) and defunding of prevention
is that early-starting, chronic conduct-problem young chil- programs (11). In contrast, we hypothesized that, and exam-
dren are at high risk to grow into antisocial adults (1), variously ined whether, adult maladjustment outcomes can be prevented
labeled as suffering from externalizing psychopathology (2), with concerted intervention, in the largest National Institutes
chronic criminals (3), having antisocial personality disorder of Health-funded randomized controlled trial to date to pre-
(4), “psychopaths” (5), or “super-predators” (6). They are also vent adult psychopathology and crime and improve well-being
at risk for internalizing psychopathology, substance abuse, by intervening among 6-year-old early-starter children.
risky sexual behavior (7), harsh parenting of offspring (7), and Developmental science models (7, 12) identify factors in
poor health and well-being (1, 3, 4). These individuals cost home and school environments that deter antisocial de-
society between $2.6 and $5.3 million in each of the following velopment. Technologies have been developed to improve
areas: incarceration, adjudication, treatment, and victims’ costs single components associated with antisocial development
(8). Although intervention evaluations document short-term outcome, including consistent and nonharsh parenting (13),
positive effects on reducing children’s antisocial behavior, no social-cognitive skills (14), positive peer relationships (15),
intervention program, to our knowledge, has ever reported academic skills (16), and a nondeviant-peer social ecology
effects for kindergarten-age children with early conduct (17). These single-component interventions have shown
problems (“early starters”) that last into adulthood, leading short-term efficacy in reducing aggressive behaviors; how-
some to doubt whether prevention is possible (9) and to ever, effects typically fade, possibly because the syndrome is

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multifactorially determined and cascades across develop- is impervious to external control. Contrary to that notion, in
ment if all facets are not addressed (18). Because these inter- the Fast Track trial thus far, intervention effects have been
ventions aim to build general skills that children can carry stronger among the highest-risk group than the moderate-
with them throughout life, they have also been employed risk group at ages 9, 12, 15, and 18 (22, 25). However, by
to prevent substance abuse, internalizing, crime, and risky age 21, adult arrest records revealed similar positive impact
sexual behavior outcomes and improve general well-being for both the highest- and moderate-risk groups. Finally, we
(7, 9, 15, 17), all of which are correlated with externalizing hypothesized robust intervention efficacy across gender, eth-
problems. nicity, and urbanicity groups.
The Fast Track prevention program began in 1991 to test
the hypothesis that comprehensive intervention that addresses
METHOD
multiple components of antisocial development and is imple-
mented continuously with early starters and their families Participants
across 10 years of childhood (1st grade through 10th grade) will Children were selected from each of three kindergarten
have an enduring impact on adult psychopathology. The pro- cohorts (from 1991–1993) at each of four geographic sites:
gram blended parent behavior-management training, child Durham, N.C.; Nashville, Tenn.; rural Pennsylvania; and
social-cognitive skills training, peer coaching and mentoring, Seattle. Elementary schools (N=55) in neighborhoods with
academic skills tutoring, and classroom social-ecology change, high rates of crime and economic disadvantage were divided
at a cost of $58,000 per child over 10 years. Program impact into paired sets (one to three sets per site) matched for de-
was tested in a randomized controlled trial that included 12 mographic characteristics, and one set was randomly as-
“mini-replications” in four geographic sites across three cohorts signed to intervention and one to a control.
of children screened at age 5 to be early starters in conduct A multiple-gating screening procedure (26) that combined
problems. teacher and parent ratings of aggressive, disruptive behavior
Intent-to-treat analyses to date indicate that the inter- was applied to all 9,594 kindergarteners (the CONSORT di-
vention was successful in promoting its proximal goals of agram is presented in the data supplement accompanying
improving parenting behavior, social-cognitive skills, peer the online version of this article). The first gate employed
relationships, academic skills, and classroom social ecology teacher-reported classroom conduct problems, using the
(19–21). It reduced 1) aggressive behavior throughout ele- Teacher Observation of Child Adjustment-Revised Authority
mentary school as reported by parents, teachers, peers, and Acceptance score (27). Children scoring in the highest 40%
blinded observers (19–21), 2) self-reported delinquent within cohort and site were solicited for the second gate of
behaviors in high school (22), and 3) juvenile (23) and screening: parent-rated home behavior problems, using a 22-
adult (unpublished data, Conduct Problems Prevention item instrument based on the Child Behavior Checklist (28).
Research Group, 2012) arrests as indicated by adminis- Teacher and parent scores were standardized within site and
trative records through age 21. Impact at grade 8 was summed to yield a severity-of-risk screen score.
negligible (24), and some outcomes yielded impact only Children were selected based on this risk score, moving
for subgroups (22). from the highest down until desired sample sizes were
The present study assessed outcomes at age 25—a full 8 reached within sites, cohorts, and conditions. A total of 979
years after the program had ended—through administrative children (10% of the total) were solicited to yield a sample of
record review and psychiatric interviews with participants 891 participating children (91% consent; intervention group,
and peer reporters who provided independent perspectives N=445; control group, N=446). At the time of selection, the
unbiased by program participation. We focused on eight domains participant mean age was 6.58 years (SD=0.48). Ethnicity
that index adult functioning: externalizing psychopathology, varied (African American, 51%; European American, 47%;
internalizing psychopathology, substance abuse, criminal con- other ethnicity, 2%), and 69% were boys. The mean exter-
viction, risky sexual behavior, aggression toward partners and nalizing problem score for the teacher-reported Child Be-
offspring, education/employment, and general well-being. We havior Checklist (29) was 1.6 standard deviations above the
hypothesized that, compared with control subjects, early start- national mean. Fifty-eight percent of children had single
ers who had been randomly assigned to intervention at age 6 parents; 29% of parents had not completed high school; and
would display a lower prevalence rate of problems in any of the 35% of families were in the lowest socioeconomic class.
three psychopathology domains (externalizing, substance abuse, Written, informed consent from parents and oral assent
and internalizing problems), fewer criminal convictions, less from children were obtained. Parents were paid for com-
risky sexual behavior, less aggressive romantic and offspring pleting interviews, and intervention group parents were paid
relationships, better education and employment, and higher for group attendance. All procedures were approved by the
general well-being scores. institutional review boards of participating universities.
We also tested intervention efficacy in subgroups of early To improve the precision of model estimates, 22 variables
starters. Some models suggest that psychosocial intervention were measured prior to intervention and included as covar-
might be efficacious with moderately high-risk children but iates in outcome analyses (plus cohort and site). These vari-
will not penetrate the highest-risk subgroup, which, presumably, ables are presented in Table 1 and described elsewhere (www.

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TABLE 1. Pre-Intervention Group Means (Standard Deviations) for Interview Participants and Nonparticipants at Age 25 by Intervention
Status
Group
All Interview All Intervention Control
Participants Nonparticipants Participants Participants
Variable Mean SD Mean SD Mean SD Mean SD
a
Male indicator 0.67 0.78 0.69 0.65
African American indicator 0.50 0.54 0.52 0.48
Initial screen score 2.05 1.01 2.01 0.96 2.05 1.00 2.06 1.01
Depression score (measured by the Feeling Scale) 16.37 10.10 16.13 10.32 15.75 9.63 16.99 10.52
Percent hostile attributions (measured by the Home 0.66 0.25 0.69 0.25 0.67 0.25 0.66 0.25
Interview with Child)
Aggressive behavior score (measured by the Home 22.38 8.25 22.24 8.02 22.62 8.46 22.15 8.04
Interview with Child)
Appropriateness score (measured by the Interview on 3.55 0.78 3.61 0.67 3.59 0.71 3.51 0.84
Emotional Experience)
Family satisfaction (measured by the Interview on 2.14 0.72 2.15 0.73 2.11 0.76 2.17 0.68
Parental Experience)
Friendship satisfaction (measured by the Interview on 2.35 0.60 2.27 0.63 2.31 0.64 2.39 0.56
Parental Experience)
Physical punishment mean score (measured by the 0.21a 0.22 0.25 0.26 0.20 0.21 0.23 0.22
Life Changes survey)
Kindergarten stress scale (measured by the Life 5.33 4.16 5.06 3.90 5.36 4.34 5.31 3.98
Changes survey)
Verbal punishment mean score (measured by the Life 0.26 0.32 0.26 0.30 0.24 0.33 0.27 0.32
Changes survey)
Socioeconomic status 24.56 12.70 23.69 12.63 24.90 12.91 24.23 12.49
Oppositional aggressive score (measured by parent 0.27 0.17 0.26 0.17 0.26 0.17 0.27 0.17
daily report)
Mean (warmth, harsh, and appropriate discipline; 2.00 0.27 2.00 0.29 2.01 0.27 1.99 0.28
measured by the Parent Questionnaire)
Total score (measured by the Social Competence 2.06 0.59 2.00 0.59 2.11b 0.58 2.01 0.59
Parent survey)
Letter and word identification (measured by 12.74 4.41 12.16 4.96 13.09b 4.78 12.39 3.97
Woodcock-Johnson tests)
Total number correct (measured by the Emotion 10.76 2.82 10.52 2.76 10.81 2.83 10.71 2.81
Recognition Questionnaire)
Warmth (measured by the Interactive Rating Scale) 3.57 0.78 3.59 0.81 3.65b 0.79 3.50 0.78
Mean percent of competent responses (measured by 0.62 0.22 0.63 0.22 0.61 0.22 0.63 0.22
the Social Problem Solving Scale)
Neighborhood Questionnaire total score –0.03 0.60 –0.07 0.59 –0.04 0.62 –0.02 0.58
Average standard Wechsler Intelligence Scale for –0.08 0.80 –0.05 0.74 –0.07 0.81 –0.10 0.79
Children score
a
Data represent significant difference (p,0.05) between age-25 interview participants and nonparticipants.
b
Data represent significant difference (p,0.05) between intervention and control age-25 interviewees.

fasttrackproject.org). Previous analyses confirm no robust sta- intervention and control groups differed significantly on three
tistical differences in these scores between intervention and variables. Among participants with peer reporters, the in-
control groups (19, 21, 22). tervention and control groups differed significantly on one
At the age-25 follow-up, participants were solicited for variable. Given that there were only seven significant differ-
interview and asked to nominate a peer who knew them well ences among 88 tests, we concluded that attrition did not
and could complete a confidential interview about them. A systematically alter the representativeness of the samples.
total of 702 participants (81% of those living) and 535 peers
(for 76% of participants; net, 62% of the total) provided data. Intervention Procedures
Participation did not differ significantly by condition (control Elementary school phase (grades 1–5). During grades 1–5,
group, N=352 [78.9%]; intervention group, N=350 [78.7%]). intervention families were offered group intervention during
As indicated in Table 1, two of the 22 preintervention variables a 2-hour “enrichment program” that included children’s so-
differed significantly (p,0.05) between interviewed and cial skill “friendship groups” (30), parent training groups (31),
noninterviewed participants. One variable significantly dif- guided parent-child interaction sessions (31), and parapro-
ferentiated participants with a peer reporter from those fessional tutoring in reading (30). Tutors provided three ad-
without a peer reporter. Among interviewed participants, the ditional 30-minute sessions per week in reading and peer

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EFFECT OF EARLY INTERVENTION ON PSYCHOPATHOLOGY

pairing to improve friendships with classmates. Teacher con- Age-25 Interviews

sultation and the teacher-implemented social-cognitive skill Condition-blinded adults were trained to interview partic-
development Fast Track PATHS (Promoting Alternative Think- ipants in person (with telephone backup). Each participant
ing Strategies) curriculum (32) were implemented universally was invited to nominate a peer for an independent interview
in grade 1–5 classrooms in intervention schools (except in about him- or herself, conducted in person in a private
Durham, N.C., where it was prohibited) to promote social- session. Participants were paid $100 for the interview and
emotional competence. Enrichment programs were held $25 for nominating a peer, and peers were paid $50.
weekly during grade 1, biweekly during grade 2, and monthly The Adult Self-Report (36) is a 132-item instrument of
during grades 3–5. In addition, home visiting (unpublished psychiatric symptoms with response options of “not true,”
data, Dodge KA, 1993) helped parents generalize their skill “somewhat or sometimes true,” and “often true.” The in-
learning and address individual needs. After grade 1, criterion- strument author’s aggregate externalizing t score and in-
referenced assessments adjusted the prescribed dosage to ternalizing t score (based on national norms within gender;
match need. mean score=50 [SD=10]) were computed. Using criteria
recommended by an international panel of judges that were
Middle and early high school phase (grades 6–10). During consistent with DSM-IV criteria (4), indicators (0=no, 1=yes)
grades 5 and 6, children received a middle school transition were computed for antisocial personality, attention deficit
program, and there were four parent-youth groups on topics hyperactivity disorder (ADHD), avoidant personality, so-
of adolescent development; alcohol, tobacco, and drugs; and matic problems, anxiety, and depression disorders. Two
decision making. In grades 7 and 8, eight youth forums (33) measures of well-being were computed: personal strength
addressed vocational opportunities, life skills, and summer from the instrument author’s scoring algorithms and a new
employment opportunities. In grades 7–10, individualized 16-item score capturing happiness (alpha=0.85).
interventions (33) addressed parent monitoring, peer affili- The Adult Behavior Checklist–Friend (36), a 132-item
ation, academic achievement, and social cognition. All chil- peer version of the Adult Self-Report, was administered to
dren received Oyserman’s School-to-Jobs possible-selves the peer respondent, yielding the same scores.
intervention (33) aimed at examining emerging identity. The Tobacco, Alcohol, and Drugs survey–version 3, is
a 57-item open-ended and forced-choice instrument based
Intervention participation. Ninety-six percent of parents and on measures from the National Longitudinal Study of Ado-
98% of children attended at least one group session during lescent Health (37) to assess frequency and problem level for
grade 1. Of these families, 79% of parents and 90% of chil- tobacco, alcohol, and illegal drug use. We created three di-
dren attended at least 50% of prescribed group sessions (34). chotomous indicators: 1) binge drinking problem (defined as
Participation decreased modestly across years, primarily five or more drinks on one or more occasion in the last
because of residential moves. In grades 7–10, intervention month and five or more drinks on 12 or more occasions in the
continued with at least 80% of all children. last year); 2) heavy marijuana use (defined as 27 or more days
High intervention fidelity was ensured by manualization, of use in the past month); and 3) serious substance use
regular cross-site training, and weekly clinical supervision. Out- (defined as use of cocaine, crack, inhalants, heroin, LSD,
side interventions were neither encouraged nor discouraged. phencyclidine, ecstasy, mushrooms, speed, or other pills not
The full intervention protocol is available online (fast- prescribed by a physician in the past month). An alcohol and
trackproject.org). drug module, adapted from the National Institute of Mental
Health Diagnostic Interview Schedule (38), was adminis-
Age-25 Administrative Records tered. DSM-IV diagnostic criteria for alcohol abuse were
Court records were collected locally and supplemented us- applied to create a diagnostic indicator. We also created an
ing a national database that included all arrests, adjudica- any substance use problem indicator, scored 1 if any of the
tions, diversions, and magistrate appearances, based on full four substance use problems were met, or 0 otherwise. The
name, birthdate, and social security number (N=817, 92%). Tobacco, Alcohol, and Drugs survey (Friend) and Alcohol
We limited offenses to convictions and diversions. Following and Drug Module (Friend) are identical peer-report instru-
previous coding systems (23, 35), we created severity-weighted ments, yielding the same scores.
indices, multiplying frequencies by severity across all lifetime We created an any externalizing, internalizing, or sub-
convictions. For violent crimes, severity levels range from 1 to 3 stance use problem indicator, scored 1 if criteria for any of the
(severity 3 includes aggravated/armed robbery, murder, rape, following problems were present, or 0 otherwise: antisocial
kidnapping, sex offenses, and first-degree assault; severity 2 personality, ADHD, avoidant personality, somatic problems,
includes robbery and first-degree burglary; and severity 1 anxiety, depression, alcohol abuse, binge drinking problem,
includes DUI and carrying a concealed weapon). Severity levels heavy marijuana use, or serious substance use.
for substance crimes range from 1 to 2 (severity 2 includes The 36-item Short-Form Health Survey (39) was ad-
manufacturing and possession with intent to sell; severity 1 ministered to participants and peers. A general health index
includes possession). Severity levels for property/public order averaged four items capturing overall health status, pres-
crimes range from 1 to 3. ence of chronic conditions, magnitude of bodily pain, and

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TABLE 2. Group Outcome Means (Standard Deviations) by Condition

Intervention Participants Control Participants
Variable N Mean or Proportion SD N Mean or Proportion SD
Any externalizing, internalizing, or substance use 362 0.59 356 0.69
problem
Externalizing t score, self- or peer-reported average 362 56.38 9.35 359 57.61 9.50
Antisocial personality DSM-IV clinical range 362 0.17 358 0.24
Attention deficit hyperactivity disorder problems 362 0.10 359 0.14
DSM-IV clinical range
Internalizing t score, self- or peer-reported average 362 55.86 10.94 359 57.95 10.80
Avoidant personality DSM-IV clinical range 362 0.09 359 0.11
Somatic DSM-IV clinical range 362 0.14 359 0.20
Anxiety DSM-IV clinical range 362 0.10 359 0.12
Depression DSM-IV clinical range 362 0.14 359 0.18
Any problematic substance use, self- or peer- 326 0.45 318 0.56
reported
Alcohol abuse 337 0.31 326 0.36
Binge drinking problem 354 0.25 351 0.30
Heavy marijuana use 355 0.09 352 0.10
Serious substance use 362 0.11 358 0.17
Overall well-being, self- and peer-reported average 360 0.06 0.74 354 –0.06 0.75
General health index 360 0.80 0.18 354 0.78 0.18
Happiness 362 23.52 4.83 359 22.69 4.96
Strength 362 17.26 2.79 359 16.98 2.91
Education and employment, self-report only
Graduated from high school or graduate 426 0.72 409 0.72
equivalency diploma
Currently full-time employed or enrolled in higher 355 0.50 356 0.50
education
Sexual experiences and romantic relationship
aggression
Number of sexual partners over lifetime, self-report 331 3.24 1.80 334 3.44 1.91
only
Risky sexual behavior in past 12 months, self-report 322 8.09 11.84 328 13.98 29.27
only
Violent acts against romantic partner, self- and 283 0.77 1.64 278 0.89 1.84
peer-reported average
Parenting
Coercive parenting 159 1.11 0.26 158 1.13 0.24
Spanking Scale 160 1.77 0.89 158 2.00 1.00
Parenting efficacy, self-report only 150 5.85 1.03 147 5.73 1.17
Parenting satisfaction, self-report only 149 4.98 1.25 147 4.92 1.25
Severity-weighted conviction indices
Substance crimes 402 0.50 1.37 403 0.58 1.71
Violent crimes 391 0.94 2.46 396 1.38 4.05
Property and public order crimes 391 2.49 6.17 395 2.32 5.16

presence of physical health issues that infringed upon work. (categories ranged from 0 to 7 capturing 0, 1–2, 3–5, 6–10,
For self- and peer-reported data, we constructed an overall 11–15, 16–20, 21–50, and 50 or more partners). For risky sexual
well-being score by averaging across the standardized general behavior in the past 12 months, the number of partners in the
health index, personal strength, and happiness scores. last year was multiplied by the sum of two scales: new-partner
Two scores (0=no, 1=yes) were created from the 8-item condom nonuse and regular-partner condom nonuse. New-
Education Information and the 46-item Employment His- partner condom nonuse ranged from 0 to 5 (no new partner,
tory measures from the National Longitudinal Surveys (40) always use condom, most times use condom, about half the
to ascertain whether the respondent graduated from high time, sometimes nonuse, and never use, respectively); con-
school or received a GED and was currently employed full- dom nonuse with the respondent’s regular partner ranged
time or enrolled in higher education. from 1 to 5 (never nonuse, most times use condom, about half
Respondents completed the 37-item Overview of Sexual the time, sometimes nonuse, and never use, respectively).
Experiences (41). The number of lifetime partners item cap- The 47-item General Violence Questionnaire (42) measured
tured risky sexual behavior over the respondent’s lifetime violence between the respondent and his or her romantic

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EFFECT OF EARLY INTERVENTION ON PSYCHOPATHOLOGY

TABLE 3. Intervention Main Effects Based on Full Information Maximum Likelihood Modelsa
Intervention Effect
Standard Odds
Variable Estimate p Ratio p 95% CI Number Needed to Treat
Any externalizing, internalizing, or substance use 0.59 0.001 0.43–0.81 8
problem
Externalizing t score, self- or peer-reported average –0.15 0.026
Antisocial personality DSM-IV clinical range 0.60 0.022 0.39–0.93 20
Attention deficit hyperactivity disorder problems 0.65 0.095 0.39–1.08
DSM-IV clinical range
Internalizing t score, self- or peer-reported average –0.20 0.002
Avoidant personality DSM-IV clinical range 0.53 0.026 0.30–0.93
Somatic DSM-IV clinical range 0.73 0.171 0.47–1.14
Anxiety DSM-IV clinical range 0.79 0.373 0.47–1.33
Depression DSM-IV clinical range 0.68 0.102 0.42–1.08
Any problematic substance use, self- or peer 0.57 0.001 0.41–0.78 8
reported
Alcohol abuse 0.69 0.045 0.48–0.99
Binge drinking problem 0.75 0.057 0.55–1.01
Heavy marijuana use 0.76 0.318 0.45–1.30
Serious substance use 0.58 0.021 0.36–0.92
Overall well-being, self- and peer-reported average 0.17 0.020
General health index 0.09 0.222
Happiness 0.19 0.008
Strength 0.10 0.111
Education and employment, self-report only
Graduated from high school or graduate 0.93 0.654 0.68–1.27
equivalency diploma
Current full-time employment or enrolled in 0.84 0.316 0.60–1.18
higher education
Sexual experiences and romantic relationship
aggression
Number of sexual partners over lifetime, self- –0.17 0.032
report only
Risky sexual behavior in past 12 months, self- –0.24 0.000
report only
Violent acts against romantic partner, self- and –18.8% 0.240
peer-reported averageb
Parenting
Coercive parenting –0.09 0.386
Spanking Scale –0.22 0.043
Parenting efficacy, self-report only 0.20 0.098
Parenting satisfaction, self-report only 0.05 0.651
Severity-weighted conviction indices
Substance crimesb –34.7% 0.027
Violent crimesb –30.9% 0.047
Property and public order crimesb –1.1% 0.937
a
Models controlled for site, cohort, and 22 preintervention control variables; the number needed to treat (NNT) was calculated using the model corrected odds
ratio (OR) and control event rate (CER) and the following formula: NNT=(1–(CER*(1–OR)))/((1–CER)*(CER)*(1–OR)).
b
Count outcome: percentage change in expected count is reported.

partners. The violent acts against romantic partners item the Being a Parent Scale and Conflict Tactics Scales (43),
summed the number of times in the past 12 months (coded completed for the oldest child. Spanking was coded as
0, 1, 2, or 3 [indicating three or more times]) the respondent 1=never, 2=1–3 times, 3=monthly, 4=weekly, and 5=most days.
did the following to any romantic partner: threatened with Coercive parenting was averaged across the following five
a knife or gun; pushed, shoved, grabbed, slapped, or threw items, each coded as above: threatened; yelled, insulted, or
something; punched, hit, kicked, bit, or slammed against a wall; swore at; hit or tried to hit with something; pushed, grabbed,
beat up or choked, strangled, burned, or scalded on purpose; or or slapped; and beat up. Parenting efficacy was averaged
used a knife or gun. Peers completed the same instrument. across six items (1=strongly disagree to 7=strongly agree)
The 24-item parenting measure was completed only capturing the respondent’s belief that he or she possessed the
for participants with offspring and included items from skills to be a good parent. Parenting satisfaction was averaged

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TABLE 4. Moderation Test Resultsa

Initial Screen
Gender (df=1) Race (df=1) Cohort (df=2) Site (df=3) (df=1)
Variable x2 p x2 p x2 p x2 p x2 p
Any externalizing, internalizing, or substance use 0.074 0.785 0.000 1.000 0.997 0.607 1.980 0.577 0.362 0.548
problem
Externalizing t score, self- or peer-reported average 0.035 0.852 0.006 0.939 4.212 0.122 0.877 0.831 0.421 0.517
Antisocial personality DSM-IV clinical range 0.081 0.776 0.013 0.908 8.346 0.015 1.948 0.583 0.014 0.906
Attention deficit hyperactivity disorder problems 0.912 0.339 0.246 0.620 6.585 0.037 2.621 0.454 1.331 0.249
DSM-IV clinical range
Internalizing t score, self- or peer-reported average 0.030 0.862 1.229 0.268 0.363 0.834 2.581 0.461 0.155 0.694
Avoidant personality DSM-IV clinical range 2.047 0.152 2.493 0.114 3.418 0.181 2.724 0.436 0.041 0.840
Somatic DSM-IV clinical range 1.863 0.172 0.074 0.785 1.144 0.565 2.351 0.503 1.229 0.268
Anxiety DSM-IV clinical range 0.169 0.681 0.029 0.864 7.302 0.026 1.997 0.573 1.166 0.280
Depression DSM-IV clinical range 0.059 0.809 0.156 0.693 20.030 0.000 4.757 0.191 0.082 0.775
Any problematic substance use, self- or peer- 0.024 0.876 0.054 0.817 0.984 0.611 4.043 0.257 1.234 0.267
reported
Alcohol abuse 2.445 0.118 0.468 0.494 1.034 0.596 0.808 0.848 3.240 0.072
Binge drinking problem 0.196 0.658 0.075 0.784 0.588 0.745 0.319 0.956 0.908 0.341
Heavy marijuana use 0.278 0.598 0.254 0.615 6.934 0.031 5.696 0.127 1.299 0.254
Serious substance use 0.161 0.688 0.468 0.494 4.696 0.096 1.460 0.691 0.142 0.707
Overall well-being, self- and peer-reported average 0.015 0.904 0.524 0.469 4.808 0.090 4.996 0.172 0.034 0.855
General health index 0.162 0.688 0.024 0.878 1.882 0.390 2.936 0.402 0.071 0.789
Happiness 0.007 0.932 0.722 0.395 2.943 0.230 3.512 0.319 0.256 0.613
Strength 0.131 0.717 1.651 0.199 4.989 0.083 5.047 0.168 0.500 0.480
Education and employment, self-report only
Graduated from high school or graduate 0.000 1.000 0.090 0.764 2.129 0.345 3.501 0.321 0.217 0.641
equivalency diploma
Currently full-time employed or enrolled in higher 0.286 0.593 0.230 0.632 1.454 0.483 10.580 0.014 0.033 0.855
education
Sexual experiences and romantic relationship
aggression
Number of sexual partners over lifetime, self-report 0.044 0.835 0.169 0.681 1.394 0.498 6.089 0.107 0.174 0.676
only
Risky sexual behavior in past 12 months, self-report 1.286 0.257 0.082 0.774 2.744 0.254 0.663 0.882 1.880 0.170
only
Violent acts against romantic partner, self- and 0.043 0.837 0.064 0.801 2.700 0.259 0.910 0.823 0.060 0.806
peer-reported average
Parenting
Coercive parenting 0.108 0.742 1.639 0.200 1.510 0.470 6.578 0.087 0.093 0.760
Spanking scale 5.553 0.018 0.227 0.634 0.126 0.939 3.871 0.276 0.883 0.347
Parenting efficacy, self-report only 0.000 1.000 0.810 0.368 0.299 0.861 1.921 0.589 0.400 0.527
Parenting satisfaction, self-report only 0.294 0.588 0.185 0.667 2.637 0.268 0.287 0.962 4.076 0.043
Severity-weighted conviction indices
Substance crimes 2.620 0.106 0.015 0.902 13.109 0.001 0.261 0.967 3.580 0.058
Violent crimes 1.062 0.303 1.355 0.244 3.400 0.183 8.657 0.034 1.575 0.209
Property and public order crimes 0.034 0.854 0.665 0.415 1.107 0.575 2.840 0.417 0.953 0.329
a
Models control for site, cohort, and 22 preintervention control variables; of 150 moderation tests, 10 were significant, but only two indicated an opposite-
direction pattern of group means.

across six reverse-coded items (1=strongly agree to 7=strongly 20% of the individual scores were missing for any variable,
disagree) capturing the respondent’s belief that being a parent the score was declared missing.
is fulfilling. Peers received an identical version. We estimated the impact of intervention on each outcome
using full information maximum likelihood to account for
Statistical Model and Treatment of Missing Data data missing at random, with standard linear regression
For each indicator, a combined score across self- and peer- models for continuous outcomes, logit models for dichotomous
interviewees equaled 1 if either the respondent or the peer outcomes, and negative binomial models for count and crime
reported that the problem was present, or 0 otherwise. For variables. We clustered standard errors by kindergarten
each continuous scale, we averaged across the self- and peer- school to account for sampling at the school level. Analyses
reported scales. If the peer-reported scale was not collected were based on an intent-to-treat design that included all
or missing, the self-reported scale was used. If more than children without regard to intervention participation. We

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EFFECT OF EARLY INTERVENTION ON PSYCHOPATHOLOGY

FIGURE 1. Rates of Clinical Problems at Age 25 for Intervention and Control RESULTS
Participants
0.8
Intervention and control prevalence rates (or
group means and standard deviations) for all
Control outcomes are presented in Table 2, with model
0.7
Intervention findings for intervention effects summarized in
Table 3. All moderation test results are reported
0.6 in Table 4 but described here only when effects
reversed direction across groups.
0.5
Any Psychiatric Problem
Children assigned to intervention were signifi-
0.4 cantly less likely than children in the control
group to exhibit any externalizing, internalizing,
0.3 or substance use problem (Figure 1). Table 5
provides evidence that the intervention-control
0.2
difference was consistent for each of 13
subgroups, which included the highest-risk
group, the moderate-risk group, male partic-
0.1
ipants, female participants, African Americans,
European Americans, cohorts 1, 2, and 3, and
0 sites in Durham, N.C., Nashville, Tenn., Seattle,
Any Any Any Any Any
Problem— Problem— Externalizing Internalizing Substance and rural Pennsylvania.
Self or Peer Self and Peer Problem— Problem— Problem— Scores from self-report only, peer-report
Self or Peer Self or Peer Self or Peer
only, and the use of an “and” rule instead of
an “or” rule yielded similar significant ef-
fects. Intervention and control rates, re-
TABLE 5. Subgroup Prevalence Rates (Numbers and Standard Deviations) for spectively, were 0.48 compared with 0.57 for
Any Externalizing, Internalizing, or Substance Use Problem self-report (p,0.02); 0.41 compared with 0.51
Intervention Control for peer-report (p,0.01); and 0.26 compared
Participants Participants with 0.35 for combined self- and peer-report
Difference
Variable Number Rate Number Rate (Intervention–Control) (p,0.02).
Male 253 0.60 230 0.70 –0.10
Female 109 0.57 126 0.67 –0.11 Externalizing, Internalizing, and
European American 176 0.68 183 0.75 –0.08 Substance Use Problems
African American 186 0.52 173 0.62 –0.11 Children assigned to intervention had sig-
Cohort 1 127 0.58 127 0.72 –0.13 nificantly lower externalizing t scores (effect
Cohort 2 131 0.61 129 0.68 –0.07
Cohort 3 104 0.59 100 0.67 –0.08
size calculated as Cohen’s d [{intervention
Durham, N.C. 96 0.44 95 0.60 –0.16 mean–control mean}/standard deviation]=0.15);
Nashville, Tenn. 81 0.57 84 0.65 –0.09 lower internalizing t scores (effect size=0.20);
Rural Pennsylvania 96 0.73 97 0.81 –0.09 and a significantly lower probability of sub-
Seattle 89 0.64 80 0.69 –0.05 stance use problems.
Highest initial risk 53 0.64 57 0.79 –0.15
Moderate initial risk 309 0.59 299 0.67 –0.09
Children assigned to intervention had sig-
nificantly lower probability of meeting criteria
for antisocial personality disorder, a marginally
controlled for cohort, site, and 22 preintervention covariates significant lower probability of ADHD, and significantly lower
and tested for moderation by gender, race, cohort, site, and probability of avoidant personality. Intervention effects were
initial screen score. For continuous outcomes, we report stan- not significant for somatic problems, anxiety, and depression.
dardized coefficients indicating the standard deviation change Assignment to intervention significantly decreased the
in the outcome associated with assignment to intervention. We probability of alcohol abuse, marginally decreased binge
report odds ratios and the number needed to treat (44) for drinking, did not affect heavy marijuana use, and signifi-
dichotomous outcomes and the percentage change in expected cantly decreased serious substance use.
counts for count outcomes (45).
Power analyses indicated sufficient power (0.80) to de- Crime
tect group differences with an odds ratio #0.65, based on Assignment to intervention significantly decreased the
a two-tailed test (p,0.05, N=729), and a control group rate expected severity-weighted violent crime conviction in-
of 0.69. dex by 31% and drug conviction index by 35%. Significant

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 DODGE ET AL.

PATIENT PERSPECTIVE
Five-year-old “Torian” lived with his mother, 7-year-old aid of program transportation. The mother was grateful
brother, and 1-year-old sister in a housing project in for the free baby-sitting offered to the sister and the
Nashville, Tenn. His mother had dropped out of school pizza lunch provided to the brother and Torian. At one
and was unemployed. He had never met his father. His group session also attended by the first-grade teacher,
mother reported difficulty keeping him out of trouble, the teacher expressed pleasure at meeting the mother for
and his kindergarten teacher reported consistent high the first time. Even though she had also taught Torian’s
levels of aggressive and disruptive behavior. Fast Track older brother 2 years earlier, she had never met the
leaders recruited the family into the program at their mother. Program leaders reported that Torian was eager
apartment, where cockroaches crawled up their legs, the to attend sessions across the first 4 years, grew reticent
broken refrigerator door swung open, a police siren in grades 5 and 6, and met privately with one leader
competed with a baby’s crying in the background, and throughout middle school. He was arrested for shop-
the front door had marks of numerous break-ins. Tor- lifting in grade 7, but charges were dropped by the ju-
ian’s mother responded affirmatively to the program’s venile court. Mother and Torian beamed at the Fast
stated goals of helping Torian’s long-term prospects of Track “graduation” at the end of 10th grade. Although he
graduating from high school, staying out of jail, and struggled, Torian graduated from high school. At age 25,
staying off drugs. he was employed part-time, lived with friends, had not
Both mother and son regularly attended Saturday been arrested as an adult, and was not diagnosed with
group sessions held at the school 14 miles away, with the any psychopathology.

moderation of the violent crime index by cohort indicated DISCUSSION

favorable intervention-control differences in cohorts 1 and 2
We found evidence that early psychosocial intervention can
but a nonsignificant opposite effect in cohort 3. Intervention
be efficacious in preventing costly adult psychopathology
did not affect property/public order crime.
and crime in a group of early-starting conduct-problem
children. Nineteen years after identification and 8 years after
Well-Being
intervention ended, relative to control subjects, individuals
Assignment to intervention increased the overall well-being
randomly assigned to intervention displayed lower preva-
and happiness scores but had no significant effect on general
lence of externalizing problems, internalizing problems,
health index and personal strength scores.
substance use problems, violent and drug crime convictions,
risky sexual behavior, and spanking of participants’ off-
Educational Attainment and Employment spring, as well as higher well-being. Intervention did not
Assignment to intervention did not affect the probability of have an impact on education or employment. Previous
graduating from high school or of being employed full-time reports of outcomes in elementary school (19–21) and high
or of higher education at age 25. school (22, 23) suggest that intervention impact cumulates
so that the effect grows in adulthood.
Sexual Experiences and Aggression in These findings were robust across self- and peer raters
Romantic Relationships and across decision metrics that applied “or” and “and”
Assignment to intervention decreased the lifetime number rules. Using a conservative “and” rule, intervention lowered
of sexual partners (effect size=0.17) and risky sexual behavior the prevalence of any problem from 30% to 21%. Clinical
in the past 12 months (effect size=0.24). Among participants interviews with the participant to obtain self-report mea-
who maintained a romantic relationship in the past year, the sures are standard practice and typically accepted as valid
intervention effect on violent acts against romantic partners (37), but they can be subject to bias by an intent to please
was not significant. program officials. Because peers had not participated in the
intervention at all, they had little reason to bias their re-
Parenting sponses and thus bring an independent source of validity to
Assignment to intervention significantly decreased spanking the findings.
of participants’ offspring (effect size=0.22). The effect was Fast Track’s efficacy did not differ across diverse sub-
significantly moderated by gender, with a stronger effect groups of participants. Twelve “mini-replications” indicated
among male participants than female participants. Inter- that the direction of intervention effects held for each of the
vention had no effect on coercive parenting, marginally in- four sites and three cohorts, as well as for both male and
creased parenting efficacy (effect size=0.20), and had no female participants, African Americans, European Ameri-
effect on parenting satisfaction. cans, moderate-risk children, and high-risk children. Of 150

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EFFECT OF EARLY INTERVENTION ON PSYCHOPATHOLOGY

moderation tests, only 10 were significant, and just two in- One limitation of this study is that the active ingredients of
dicated nonsignificant reversal of direction for subgroups. the intervention are not clear. The multicomponent inter-
These analyses did not test whether the intervention ef- vention was designed based on a developmental science model
fect was statistically significant within each subgroup that stipulated multiple factors in the development of antiso-
because of limited power, but we conclude that this in- cial behavior. No attempt was made experimentally to deliver
tervention is appropriately targeted toward diverse groups partial treatments to determine which components were crit-
of children. ical to impact, nor was any attempt made to encourage or block
These findings contribute to our understanding of the families from receiving outside interventions.
developmental antecedents of adult psychopathology. Most The most important conclusion from this study is that a
models acknowledge the role of biological predispositions, comprehensive, multicomponent developmental science-based
through temperament and still-underidentified genetic factors intervention targeted toward early-starting conduct-problem
(1, 12). Models of development that incorporate the role of children can significantly reduce adult psychopathology and
environmental experiences with parents, peers, and school violent crime. The findings run counter to claims that pre-
have relied largely on correlational evidence subject to selec- vention fails, made by advocates of cuts to federal funding for
tion biases (11, 12). Even gene-by-environment interaction prevention (10), which are already only 3% of total health care
models utilize environmental evidence that is correlational. spending. This finding should encourage policies and pro-
The present study contributes experimental evidence about grams that acknowledge both the risk and the malleability of
the contribution of environmental experience: random as- early-starting conduct-problem children.
signment to a psychosocial intervention that attempted to
change a child’s environmental experiences did indeed lead to AUTHOR AND ARTICLE INFORMATION
changes in adult psychopathology outcomes. The findings are From Duke University, Durham, N.C.; Pennsylvania State University,
consistent with a developmental cascade model (46) in which University Park; the University of Alabama, Tuscaloosa.; Simon Fraser
changes in skills and social experiences early in life cascade University, Vancouver, British Columbia, Canada; and Tufts University,
Boston.
into changes in broader outcomes many years later. Future
Address correspondence to Dr. Dodge (dodge@duke.edu).
studies will examine mediators of impact on adult outcomes
to test developmental models more directly. Supported by NIMH grants R18 MH48043, R18 MH50951, R18 MH50952,
R18 MH50953, K05MH00797, and K05MH01027; Department of Educa-
Future analyses will evaluate the degree to which the Fast
tion grant S184U30002; and National Institute on Drug Abuse grants
Track intervention is financially cost beneficial. The in- DA16903, DA017589, K05DA015226, and P30DA023026. The Center for
tervention is a 10-year investment at a cost of $58,000 per Substance Abuse Prevention and the National Institute on Drug Abuse
child. The present findings indicate a modest reduction by also provided support through a memorandum of agreement with NIMH.
9 percentage points in prevalence of externalizing, inter- The authors thank the Durham Public Schools, the Metropolitan Nashville
nalizing, and substance problems as a result of intervention. Public Schools, the Bellefonte Area Schools, the Tyrone Area Schools, the
Mifflin County Schools, the Highline Public Schools, and the Seattle Public
The number of children needed to treat in order to reduce
Schools. The authors also thank the staff members who implemented the
expected outcome “caseness” by one is 8, suggesting that the project, collected the evaluation data, and assisted with data management
intervention would be cost beneficial if the cost of a single and analyses.
case of adult psychopathology exceeds $644,444 (calculated
Drs. Bierman, Coie, Dodge, Greenberg, Lochman, and McMahon are the
as $58,000/0.09). The cost to society of one case of adult developers of the Fast Track curriculum and have a publishing agree-
psychopathology is not yet known precisely. The cost of ment with Oxford University Press. Dr. Greenberg is an author on the
chronic criminality has been estimated at up to $5.3 million PATHS (Promoting Alternative Thinking Strategies) curriculum and has
per case (7), suggesting that the Fast Track intervention a royalty agreement with Channing-Bete, and he is also a principal in
PATHS Training, LLC. Dr. McMahon has a royalty agreement with Guil-
might well yield high dividends and exceed conservative
ford Publications, and he is also a member of the Treatments That Work
benefit-cost tests. Additional benefits likely accrue from the Scientific Advisory Board with Oxford University Press. All other authors
impact of Fast Track on reducing risky sexual behavior and report no financial relationships with commercial interests.
improving parenting and well-being. The benefit-cost ratio This study is registered at clinicaltrials.gov (registry number, NCT01653535)
of this intervention should be compared with that of other and Prevent Violence Trials Registry (http://www.preventviolence.info/trial.
approaches, such as prenatal home visiting to families selected aspx?id=3f511162-eecd-4277-a27c-a08a016869fe) as Multisite Prevention
of Conduct Problems (Fast Track).
based on demographic risk (47). However, even if the Fast
Track intervention proves to be cost beneficial, other factors Received June 17, 2013; revisions received Feb. 2 and May 23, 2014;
accepted June 24, 2014.
might well make it difficult to implement at scale, including
the absolute cost and the length of commitment required by
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