MULTISYSTEMIC THERAPY (MST): BASES OF SUCCESS IN TREATING SERIOUS CLINICAL PROBLEMS IN CHILDREN AND ADOLESCENTS

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MULTISYSTEMIC THERAPY (MST)BASES OF SUCCESS IN
TREATING SERIOUS CLINICAL PROBLEMS IN CHILDREN
AND ADOLESCENTS

• Scott W. Henggeler, Ph.D., Director
• Family Services Research Center
• Department of Psychiatry and Behavioral Sciences
• Medical University of South Carolina
• Charleston

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FAMILY SERVICES RESEARCH CENTER

• Scott W. Henggeler, Ph.D., Director
• Cynthia Cupit Swenson, Ph.D., Associate Director
• Sonja K. Schoenwald, Ph.D.
• Phillippe B. Cunningham, Ph.D.
• Colleen Halliday-Boykins, Ph.D.
• Elizabeth Letourneau, Ph.D.
• Jeff Randall, Ph.D.
• Melisa D. Rowland, M.D.
• Lisa Saldana, Ph.D.
• Ashli Sheidow, Ph.D.
• Jason Chapman, Ph.D.

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FSRC MISSION

• To develop, validate, and study the
  dissemination of clinically effective and cost
  effective mental health and substance abuse
  services for youths presenting serious clinical
  problems and their families

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OTHER MST-RELATED ORGANIZATIONS

• MST SERVICES (has license with Medical University
  of South Carolina for transport of MST technology
  and intellectual property)
• Mission Assists organizations in development
  of MST programs and builds (or provides)
  internal capacity of organization to maintain
  quality assurance system
• MST INSTITUTE
• Mission To facilitate the dissemination of
  evidence-based practices with high treatment
  fidelity
• NETWORK PARTNERS in Ohio, Hawaii, Colorado,
  Tennessee, Pennsylvania, Connecticut, and Norway

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Disclosure Statement

• Presenter is stockholder in MST Services Inc.,
  which has the exclusive licensing agreement
  through the Medical University of South Carolina
  for the transport of MST technology and
  intellectual property.

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STRUCTURE OF MST

• Treatment targets serious juvenile offenders at
  high risk for out-of-home placement and their
  families
• MST team includes 3-4 masters level therapists
  and a 50 time supervisor
• Therapists provide services 24/7
• Therapists carry caseloads of 4-6 families each
  for an average of 4 months
• Services are provided in homes and other
  community settings
• MST team is supported by intensive quality
  assurance system to optimize youth outcomes

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CRITICAL COMPONENTS OF MST

• 1. Addresses the known causes of antisocial
  behavior comprehensively -- at youth, family,
  peer, school, and community levels
• 2. Provides intensive treatment where problems
  occur in homes, schools, and neighborhoods
• 3. Views caregivers as central to achieving
  favorable youth outcomes family-based
• 4. Intensive quality assurance system supports
  MST program fidelity and youth outcomes
• 5. MST provider organizations are accountable
  for family engagement and youth outcomes

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Principles of MST

• 1. Finding the Fit
• 2. Positive Strength Focused
• 3. Increasing Responsibility
• 4. Present-focused, Action-oriented
  Well-defined
• 5. Targeting Sequences
• 6. Developmentally Appropriate
• 7. Continuous Effort
• 8. Evaluation and Accountability
• 9. Generalization

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PUBLISHED MST OUTCOMES

• 10 Randomized Trials and 1 Quasi-Experimental
  Trial Published (gt1000 families participating)
• 3 with violent and chronic juvenile offenders
• 1 with substance abusing or dependent juvenile
  offenders
• 2 with juvenile offenders
• 1 with juvenile sexual offenders
• 2 with youths presenting serious emotional
  disturbance
• 1 with maltreating families
• 1 with adolescents with poorly controlled
  diabetes
• Approximately 10 additional randomized trials are
  in progress

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OVERVIEW OF MST OUTCOMES ASSOCIATED WITH

• Criminal Behavior Violence
• Adolescent Substance Abuse
• Adolescent Sexual Offending
• Mental Health
• Child Maltreatment

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PUBLISHED OUTCOMES FOR CRIMINAL BEHAVIOR

• 4 Randomized and 1 quasi-experimental trials
  with serious juvenile offenders
• Decreased recidivism (25 to 70) for as long as
  13 years post treatment
• Decreased self-reported criminal offending
• Decreased out-of-home placement (47 to 64
  reductions)
• Decreased behavior problems
• Improved family relations
• Considerable cost savings (Washington State
  Institute on Public Policy)
• 1. MST 64,000/youth
• 15. Bootcamps ( 7,910)/youth

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Simpsonville, SC Project
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Missouri Delinquency Project
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MST Substance-Related Clinical Outcomes

• Serious juvenile offenders two trials
• decreased self-reported substance use
• fewer drug-related arrests at 13-year follow-up
• Diagnosed substance abusing/dependent juvenile
  offenders
• decreased self-reported substance use
• increased attendance in regular school settings
• 98 (57 of 58 families) treatment completion (
• Incremental costs of MST offset by savings
  incurred from reductions in days of out-of-home
  placement at 12 months

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Long-Term Outcomes for Substance Abusers

• 4-year treatment effects for violent criminal
  behavior (.15 versus .57 arrests per year)
• higher rates of marijuana abstinence for MST
  participants at 4-years post treatment (55
  versus 28)

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MST 12-MONTH OUTCOMES FROM JUVENILE DRUG COURT
RANDOMIZED TRIAL (N161)

• Compared with regular drug court, MST had
• fewer positive screens 20 versus 60 (2,000
  screens)
• less self-reported alcohol and polydrug use
• marginally decreased mental health symptoms
  (CBCL)

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MST OUTCOMES ASSOCIATED WITH ADOLESCENT SEXUAL
OFFENDING

• Study with N16
• 3 year rearrest data for sexual offending
  favoring MST (12.5 versus 75)
• Replication study with N48
• 8-year rearrest data for sexual offending
  favoring MST (12.5 versus 41.7)
• 66 decrease in days incarcerated
• Effectiveness study underway in Chicago

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MST MENTAL HEALTH OUTCOMES-Alternative to
Psychiatric Hospitalization Study

• Decreased youth externalizing
• Improved family functioning
• Increased school attendance
• At 4 months post referral MST youth had a 72
  reduction in days hospitalized and a 49
  reduction in days in other out-of-home placements
• Higher consumer satisfaction
• Positive effects dissipated by 1.5 years
• Similar findings in (N36) replication study in
  Hawaii

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MST OUTCOMES ASSOCIATED WITH CHILD MALTREATMENT

• Improved parent-child interactions
• Current Trial with Child Physical Abuse
• Effectiveness Trial (MST versus Group Behavioral
  Parent Training) with 160 families with an
  indicated case of physical abuse

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BASES OF MST SUCCESS

• 1. Addresses multidetermined nature of serious
  clinical problems
• 2. High ecological validity of intensive
  services
• 3. Intensive quality assurance (improvement)
  system
• 4. Integration of evidence-based intervention
  models
• 5. Caregiver viewed as key to long term outcomes
• 6. Program accountability for family engagement
  and outcomes

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1. MST ADDRESSES MULTIDETERMINED NATURE
OF SERIOUS CLINICAL PROBLEMS

• Decades of Rigorous Research Show Serious
  Adolescent Problems Linked with
• Individual adolescent characteristics
• Family functioning
• Caregiver functioning
• Association with deviant peers
• School performance
• Indigenous family support network
• Neighborhood characteristics

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MST

• Addresses risk factors across the social ecology
  (comprehensive services)
• Builds protective factors across the social
  ecology
• Accomplishes such on an individualized basis

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2. MST SERVICES HAVE HIGH ECOLOGICAL VALIDITY
AND ARE INTENSIVE

• Home-Based Model of Service Delivery
• Services provided in home, school, and community
  settings (where problems occur)
• Overcomes most barriers to service access
• Increases validity of assessment data
• Increases validity of outcome data
• Helps engage family in treatment
• Enhances treatment generalization

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INTENSIVE SERVICES

• Low therapist caseloads (4-6 families)
• 24 hour/7 day availability of therapist
• 60 to 100 hours of direct therapist-family
  contact over 4 months
• Therapists work in teams with significant
  clinical support

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3. OVERVIEW OF MSTQUALITY ASSURANCESYSTEM

• System is predicated on linkage between therapist
  fidelity to MST treatment protocols and
  child/family outcomes
• Such a linkage is supported by 6 published
  studies

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MST QUALITY ASSURANCE SYSTEM

• To Promote Treatment Fidelity, Achieve Outcomes,
  and Address Barriers to Outcomes
• Specified treatment protocol ( Henggeler et al.,
  1998, Guilford Press)
• Specified supervisory protocol (Henggeler
  Schoenwald, 1998)
• Specified consultation protocol (Schoenwald,
  1998)
• Ongoing consultation to address organizational
  barriers to program success

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MST QUALITY ASSURANCE SYSTEM
Organizational Context
Manualized
Manualized
Youth/ Family
Supervisor
Therapist
Supervisory Adherence Measure
Therapist Adherence Measure
Manualized
Manualized
MST Consultants/ MST Institute
Internet communication Person to Person
communication
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MST QUALITY ASSURANCE SYSTEM

• On site 5-day orientation training
• Quarterly booster training
• Clinicians work within MST teams for peer support
• On site clinical supervision from MST-trained
  supervisor
• Weekly consultation with MST expert via
  conference call
• Standardized adherence ratings from caregiver via
  internet system ltwww.mstinstitute.orggt
• Expert coding of audiotaped treatment sessions
  for adherence (research studies only)

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MST QUALITY ASSURANCE SYSTEM
Organizational Context
Manualized
Manualized
Youth/ Family
Supervisor
Therapist
Supervisory Adherence Measure
Therapist Adherence Measure
Manualized
Manualized
MST Consultants/ MST Institute
Internet communication Person to Person
communication
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4. INTERVENTION STRATEGIES USED WITHIN MST

• MST Programs Rely on Evidence-Based
  Interventions
• Behavior therapy
• Cognitive behavior therapy
• Pragmatic family therapies
• Pharmacological interventions (e.g., ADHD)
• Community Reinforcement Approach (Budney
  Higgins)

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BUT, Evidence-Based Interventions Are Used
Within

• Social ecological conceptual model
• Program commitment to remove barriers to service
  access
• Intensive quality assurance
• View that caregivers are key to long-term
  outcomes
• Program philosophy that emphasizes provider
  accountability for outcomes

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5. CAREGIVERS ARE VIEWED AS THE KEY TO LONG-TERM
OUTCOMES

• Hence
• Most clinical resources devoted to developing
  capacity of caregiver to achieve goals
• Significant clinician attention devoted to
  delineating and overcoming barriers to effective
  parenting (e.g., caregiver mental health
  problems, substance abuse, stress)
• Focus on family versus youth

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6. MST PROGRAMS ARE ACCOUNTABLE FOR ENGAGEMENT
AND OUTCOMES

• High Accountability Requires Access to Resources
• High salaries
• Low caseloads
• Strong clinical support
• Strong organizational support
• Sharing in program success (i.e., reducing
  placements)
• Opportunity to enhance competencies when success
  rates are low

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SCIENCE TO PRACTICE TRANSPORT OF MST TO
COMMUNITY SETTINGS

• MST Services licensed through the Medical
  University of South Carolina supports MST
  program development and provides or supports
  ongoing training and quality assurance worldwide
• 301 licensed MST programs in 30 states and 8
  nations
• Statewide initiatives in Connecticut, Hawaii,
  Ohio, and South Carolina. Nationwide initiatives
  in Norway and Denmark
• MST programs serve 10,000 serious juvenile
  offenders annually, 3 of the eligible population

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MAJOR CHALLENGES TO DISSEMINATION

• Funding structures often favor incarceration and
  residential treatment over community-based
  services
• Clinical services differ significantly from the
  status quo (e.g., home- and family-based 24/7
  availability of therapists)
• Training and quality assurance standards
  emphasize treatment fidelity and provider
  accountability, which contrast with existing
  practices and are often not desired
• Perhaps the key research and implementation issue
  is determining what promotes the effectiveness of
  dissemination sites, which have varying outcomes

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POLICY IMPLICATIONS

• 1. Shift Funding from Ineffective
  Institution-Based Services to Intensive and
  Effective Community-Based Services
• 70 of current service dollars spent on
  out-of-home placements
• Savings can fund
• higher salaries for effective clinicians
• prevention programs
• early intervention programs

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Policy Implications - continued2. Change
training and clinical practice

• Currently
• Minimal outcome accountability
• Train and hope approach to technology transfer
  dominates
• Degrees are licenses to practice as one desires
  until retirement
• Change to Performance Contracts to Promote
• Accountability
• Outcomes
• Use of evidence-based practices

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QUESTIONS OR MORE INFORMATION

• Research Related Scott W. Henggeler
  lthenggesw_at_musc.edugt
• Publication Requests ltmusc.edu/fsrcgt
• Dissemination/Site Development
• Marshall Swenson, 843 856-8226
  ltmarshall.swenson_at_mstservices.comgt