Effects of multisystemic therapy through midlife: A 21.9-year follow-up to a randomized clinical trial with serious and violent juvenile offenders.

Objective: Although current evidence suggests that the positive effects of multisystemic therapy (MST) on serious crime reach as far as young adulthood, the longer term impact of MST on criminal and noncriminal outcomes in midlife has not been evaluated. In the present study, the authors examined a broad range of criminal and civil court outcomes for serious and violent juvenile offenders who participated on average 21.9 (range = 18.3–23.8) years earlier in a clinical trial of MST (C. M. Borduin et al., 1995). Method: Participants were 176 individuals who were originally randomized to MST or individual therapy (IT) during adolescence and averaged 3.9 arrests for felonies prior to treatment. Arrest, incarceration, and civil suit data were obtained in middle adulthood when participants were on average 37.3 years old. Results: Intent-to-treat analyses showed that felony recidivism rates were significantly lower for MST participants than for IT participants (34.8% vs. 54.8%, respectively) and that the frequency of misdemeanor offending was 5.0 times lower for MST participants. In addition, the odds of involvement in family-related civil suits during adulthood were twice as high for IT participants as for MST participants. Conclusions: The present study represents the longest follow-up to date of an MST clinical trial and demonstrates that the positive impact of an evidence-based youth treatment such as MST can last well into adulthood. Implications of the authors' findings for policymakers and service providers are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

A randomized clinical trial of multisystemic therapy with juvenile sexual offenders: Effects on youth social ecology and criminal activity.

A randomized clinical trial evaluated the efficacy of multisystemic therapy (MST) versus usual community services (UCS) for 48 juvenile sexual offenders at high risk of committing additional serious crimes. Results from multiagent assessment batteries conducted before and after treatment showed that MST was more effective than UCS in improving key family, peer, and academic correlates of juvenile sexual offending and in ameliorating adjustment problems in individual family members. Moreover, results from an 8.9-year follow-up of rearrest and incarceration data (obtained when participants were on average 22.9 years of age) showed that MST participants had lower recidivism rates than did UCS participants for sexual (8% vs. 46%, respectively) and nonsexual (29% vs. 58%, respectively) crimes. In addition, MST participants had 70% fewer arrests for all crimes and spent 80% fewer days confined in detention facilities than did their counterparts who received UCS. The clinical and policy implications of these findings are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost–benefit analysis of multisystemic therapy with serious and violent juvenile offenders.

This study investigated the economics of multisystemic therapy (MST) versus individual therapy (IT) using rearrest data from a 13.7-year follow-up (Schaeffer & Borduin, 2005) of a randomized clinical trial with serious juvenile offenders (Borduin et al., 1995). Two types of benefits of MST were evaluated: The value to taxpayers was derived from measures of criminal justice system expenses (e.g., police and sheriff's offices, court processing, jails, community supervision), and the value to crime victims was derived in terms of both tangible (e.g., property damage and loss, health care, police and fire services, lost productivity) and intangible (e.g., pain, suffering, reduced quality of life) losses. Results indicated that the reductions in criminality in the MST versus IT conditions were associated with substantial reductions in expenses to taxpayers and intangible losses to crime victims, with cumulative benefits ranging from $75,110 to $199,374 per MST participant. Stated differently, it was estimated that every dollar spent on MST provides $9.51 to $23.59 in savings to taxpayers and crime victims in the years ahead. The economic benefits of MST, as well as its clinical effectiveness, should be considered by policymakers and the public at large in the selection of interventions for serious juvenile offenders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence.

Examined the long-term effects of multisystemic therapy (MST) vs individual therapy (IT) on the prevention of criminal behavior and violent offending among 176 juvenile offenders at high risk for committing additional serious crimes. Results from multiagent, multimethod assessment batteries conducted before and after treatment showed that MST was more effective than IT in improving key family correlates of antisocial behavior and in ameliorating adjustment problems in individual family members. Moreover, results from a 4-year follow-up of rearrest data showed that MST was more effective than IT in preventing future criminal behavior, including violent offending. The implications of such findings for the design of violence prevention programs are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevention of CNS disease in intermediate-risk acute lymphoblastic leukemia: comparison of cranial radiation and intrathecal methotrexate and the importance of systemic therapy: a Childrens Cancer Group report

PURPOSE: This study (Childrens Cancer Group [CCG]-105) was designed in part to determine in a prospective randomized trial whether intrathecal methotrexate (IT MTX) administered during induction, consolidation, and maintenance could provide protection from CNS relapse equivalent to that provided by cranial radiation (CXRT) in children with acute lymphoblastic leukemia (ALL) and intermediate-risk features. PATIENTS AND METHODS: We randomized 1,388 children with intermediate-risk ALL to the two CNS regimens. They received either IT MTX at intervals throughout their course of therapy or CXRT (18 Gy) during consolidation with IT MTX during induction, consolidation, and delayed intensification. Systemic therapy was randomized to one of four treatment regimens derived from a regimen used by CCG in recent studies for this patient population and three more intensive regimens based on the Berlin-Frankfurt-Munster trials. RESULTS: Life-table estimates at 7 years show a 93% and 91% CNS relapse-free survival rate for the CXRT and IT MTX groups, respectively. The corresponding event-free survival (EFS) rates are 68% and 64%. The differences are not significant. Patients who received more intensive systemic therapy had a 94% CNS relapse-free survival rate on either CXRT or IT MTX, while patients who received standard systemic therapy had 90% and 80% rates for CXRT and IT MTX, respectively (P < .0001). Patients less than 10 years of age who received CXRT or IT MTX had 72% and 71% EFS rates if they received more intensive systemic therapy. Patients 10 years or older who received CXRT had an improved EFS (61% v 53%) with a more intensive systemic program. This was primarily due to fewer bone marrow relapses (P = .04). CONCLUSIONS: IT MTX during induction, consolidation, and maintenance provides protection from CNS relapse in patients with intermediate-risk ALL equivalent to that provided by CXRT if more intensive systemic therapy is given. The CNS relapse rate with either CXRT or IT MTX is in part dependent on the associated systemic therapy. For intermediate-risk patients less than 10 years of age, IT MTX with an intensified systemic regimen provided CNS prophylaxis comparable to that provided by CXRT, whereas older patients had fewer systemic relapses if they received CXRT.     

A randomized walking trial in postmenopausal women: effects on physical activity and health 10 years later

BACKGROUND: It is important to determine if permanent lifestyle changes may result from physical activity interventions and whether health may be affected by these changes. OBJECTIVE: To conduct a 10-year follow-up of physical activity and self-reported health status in participants of a randomized clinical trial of walking intervention. METHODS: Of the original 229 volunteer postmenopausal women who participated in the original clinical trial, 196 (N = 96 intervention and 100 controls) completed the 10-year follow-up telephone interview. The interview protocol included questions on self-reported walking for exercise and purposes other than exercise, the Paffenbarger sport and exercise index, functional status, and various chronic diseases and conditions. RESULTS: The median values for both usual walking for exercise and total walking were significantly higher for walkers compared with controls (for both, P = .01), with median differences of 706 and 420 kcal/wk, respectively. After excluding women who reported heart disease during the original trial, 2 women in the walking group (2%) and 11 women in the control group (12%) reported physician-diagnosed heart disease over the last 10 years (P = .07). There were also fewer hospitalizations, surgeries, and falls among women in the walking group, although these differences were not statistically significant (P>.05). CONCLUSIONS: Although limited by self-report, this study may be the first to demonstrate long-term exercise compliance to a randomized control trial in older women and to suggest that health benefits may have ensued as a result of these increased activity levels.     

What happens with patients after participation in a clinical trial?

107 patients with primary hypercholesterolaemia participated for five years in a clinical trial with dietary and drug treatment (a statin) at the Lipid Clinic. At the end of the study the patients were referred back to their own physicians, with written advice on diet and drug therapy. At a recall two years later we studied to what extent recommended therapy and follow-up had been implemented. 15% had no follow-up after participating in the study and 18% had not measured their cholesterol for one year or more. The majority of the patients did not follow the recommended diet and level of physical activity satisfactorily, and 20% had stopped their lipid-lowering medication. In general they had been prescribed too low doses of the lipid-lowering agent, and 70% of the patients had not reached the target of the LDL-cholesterol. In conclusion, adequate treatment and a five-year follow-up is not sufficient to keep the patient compliant when the follow-up becomes less intensive. When a clinical trial is terminated, greater efforts should be made to secure better compliance to therapy.     

The cost and cardioprotective effects of enalapril in hypertensive patients with left ventricular dysfunction

This study examined the effect of enalapril on survival, resource use, and cost of care in patients with left ventricular dysfunction and hypertension using a retrospective analysis of patients who participated in the Studies of Left Ventricular Dysfunction (SOLVD). Among the 6797 SOLVD participants, 1917 patients had either elevated systolic (> or = 140 mm Hg) or diastolic (> or = 90 mm Hg) blood pressure. Therapy with enalapril was associated with a significant relative risk reduction for mortality (RR = 0.819, 95% CI: 0.68 to 0.98; P = .03). This resulted in a gain of 0.11 years (95% CI: 0.00 to 0.20 years) of survival during the average 2.8 year follow-up for this subgroup and was projected to result in a gain of 2.14 years (95% CI: 0.05 to 4.21 years) during the patient's lifetime. Enalapril significantly reduced the risk of first hospitalization for heart failure by 37%. For all types of hospitalizations, there was an average reduction of 32 hospitalizations per 100 patients treated with enalapril during the trial period (95% CI: 11.8 to 52.2 hospitalizations avoided per 100 patients), resulting in an estimated net savings of $1656 per patient during the trial period (95% CI: increased cost of $191 to savings of $3502). Although the projected lifetime net savings of $1456 was not significant (95% CI: increased cost of $9243 to saving of $12,527), evaluation of the cost per life year saved indicated that enalapril represented a cost-effective strategy. The estimated clinical benefit of enalapril among the hypertensive subgroup in SOLVD supports the recommendation that angiotensin converting enzyme (ACE) inhibitors should be considered as first line pharmacologic therapy for hypertensive patients with left ventricular dysfunction. From both the clinical and economic viewpoints, ACE inhibitors provide important clinical benefits and are cost-effective.     

Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy.

Objective: A randomized trial assessed the effectiveness of a 2-level strategy for implementing evidence-based mental health treatments for delinquent youth. Method: A 2 × 2 design encompassing 14 rural Appalachian counties included 2 factors: (a) the random assignment of delinquent youth within each county to a multisystemic therapy (MST) program or usual services and (b) the random assignment of counties to the ARC (for availability, responsiveness, and continuity) organizational intervention for implementing effective community-based mental health services. The design created 4 treatment conditions (MST plus ARC, MST only, ARC only, control). Outcome measures for 615 youth who were 69% male, 91% Caucasian, and aged 9–17 years included the Child Behavior Checklist and out-of-home placements. Results: A multilevel, mixed-effects, regression analysis of 6-month treatment outcomes found that youth total problem behavior in the MST plus ARC condition was at a nonclinical level and significantly lower than in other conditions. Total problem behavior was equivalent and at nonclinical levels in all conditions by the 18-month follow-up, but youth in the MST plus ARC condition entered out-of-home placements at a significantly lower rate (16%) than youth in the control condition (34%). Conclusions: Two-level strategies that combine an organizational intervention such as ARC and an evidence-based treatment such as MST are promising approaches to implementing effective community-based mental health services. More research is needed to understand how such strategies can be used effectively in a variety of organizational contexts and with other types of evidence-based treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and family modalities.

This randomized clinical trial compared the relative efficacy of individual (child) cognitive-behavioral therapy (ICBT), family cognitive-behavioral therapy (FCBT), and a family-based education/support/ attention (FESA) active control for treating anxiety disordered youth ages 7-14 years (M = 10.27). Youth (N = 161; 44% female; 85% Caucasian, 9% African American, 3% Hispanic, 3% other/mixed) with a principal diagnosis of separation anxiety disorder, social phobia, or generalized anxiety disorder and their parents participated. Outcome analyses were conducted using hierarchical linear models on the intent-to-treat sample at posttreatment and 1-year follow-up using diagnostic severity, child self-reports, parent reports, and teacher reports. Chi-square analyses were also conducted on diagnostic status at post and 1-year follow-up. Children evidenced treatment gains in all conditions, although FCBT and ICBT were superior to FESA in reducing the presence and principality of the principal anxiety disorder, and ICBT outperformed FCBT and FESA on teacher reports of child anxiety. Treatment gains, when found, were maintained at 1-year follow-up. FCBT outperformed ICBT when both parents had an anxiety disorder. Implications for treatment and suggestions for research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Infidelity and Behavioral Couple Therapy: Optimism in the Face of Betrayal.

Infidelity is a common issue with which distressed couples and their therapists grapple. However, there are no data on the efficacy of commonly used therapies to treat couples in which there has been an affair. In the present exploratory study, the authors examined the therapy outcomes of a sample of infidelity couples (n=19) who had participated in a randomized clinical trial of marital therapy (N=134). Results show that infidelity couples began treatment more distressed than noninfidelity couples; however, evidence suggests that couples who had an affair and who revealed this affair prior to or during therapy showed greater improvement in satisfaction than noninfidelity couples. Implications for therapy with infidelity couples are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparison of two community alternatives to incarceration for chronic juvenile offenders

The relative effectiveness of group care (GC) and multidimensional treatment foster care (MTFC) was compared in terms of their impact on criminal offending, incarceration rates, and program completion outcomes for 79 male adolescents who had histories of chronic and serious juvenile delinquency. Results show that boys who participated in MTFC had significantly fewer criminal referrals and returned to live with relatives more often. Multiple regression analyses showed that assignment to a treatment condition (i.e., GC or MTFC) predicted official and self-reported criminality in follow-up beyond other well-known predictors of chronic juvenile offending (i.e., age at 1st offense, number of previous offenses, age at referral).     

A controlled smoking cessation trial for substance-dependent inpatients.

Smoking treatment for newly recovering drug and alcohol-dependent smokers in a residential rehabilitation program was examined. The randomly assigned conditions (n?=?50 each) were multicomponent smoking treatment (MST), MST plus generalization training of smoking cessation to drug and alcohol cessation (MST+G), or usual care (UC). Fifty participants who declined smoking treatment (treatment refusers) also were studied. Both treatment conditions achieved continuous smoking abstinence rates (MST: 12%. MST+G: 10%, at 12-month follow-up) that were significantly higher than in the UC condition (0%). The MST condition had a continuous drug and alcohol abstinence rate that was significantly higher than that of the MST+G condition (40% vs. 20% at 12-month follow-up) although neither differed significantly from that of the UC condition (33%). These results support the feasibility of smoking treatment for this population and provide information regarding appropriate treatment components. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multisystemic therapy for adolescents with poorly controlled type I diabetes: Stability of treatment effects in a randomized controlled trial.

The primary purpose of the present study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, improved regimen adherence, metabolic control, and rates of hospitalization for diabetic ketoacidosis (DKA) among adolescents with chronically poorly controlled Type 1 diabetes 6 months after the completion of treatment. A randomized controlled trial was conducted with 127 adolescents and their families. Mean participant age was 13.2 years. Sixty-three percent of participants were African American, and 51% were female. Data were collected at baseline, treatment termination, and 6-month follow-up. Changes in glycated hemoglobin (HbA1c), frequency of blood glucose testing (BGT), and rate of DKA admissions were assessed. In intent-to-treat analyses, a main effect of MST on DKA admissions was found at both treatment termination and follow-up. Improvements in BGT were moderated by family composition; only 2-parent MST families maintained improvements at follow-up. Improvements in HbA1c for the MST group at treatment termination were lost at follow-up. Results show that intensive, home-based psychotherapy created stable reductions in serious lapses in adherence, as indexed by episodes of DKA, among youth with poorly controlled diabetes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rapid response predicts treatment outcomes in binge eating disorder: Implications for stepped care.

The authors examined rapid response in 75 overweight patients with binge eating disorder (BED) who participated in a randomized clinical trial of guided self-help treatments (cognitive-behavioral therapy [CBTgsh] and behavioral weight loss [BWLgsh]). Rapid response, defined as a 65% or greater reduction in binge eating by the 4th treatment week, occurred in 62% of CBTgsh and 47% of BWLgsh participants. Rapid response was unrelated to most patient characteristics except for eating psychopathology and depressive symptoms. Participants with rapid response were more likely to achieve binge remission and had greater improvements in overall eating pathology and depressive symptomatology than participants without rapid response. Rapid response had different prognostic significance for the 2 treatments. In terms of binge eating, participants receiving CBTgsh, but not BWLgsh, did equally well regardless of whether they experienced rapid response. In terms of increasing restraint and weight loss, participants with rapid response receiving BWLgsh had greater restraint and weight loss than participants receiving CBTgsh. Rapid response has utility for predicting outcomes, provides evidence for specificity of treatment effects, and has implications for stepped care treatment models of BED. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Couple and individual adjustment for 2 years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy.

Follow-up data across 2 years were obtained on 130 of 134 couples who were originally part of a randomized clinical trial comparing traditional versus integrative behavioral couple therapy (TBCT vs. IBCT; A. Christensen et al., 2004). Both treatments produced similar levels of clinically significant improvement at 2 years posttreatment (69% of IBCT couples and 60% of TBCT couples). Both treatments showed a "hockey-stick" pattern of change in which satisfaction dropped immediately after treatment termination but then increased for most of follow-up. The break point when couples reversed courses and gained in satisfaction occurred sooner for IBCT than TBCT couples, and those couples who stayed together generally fared better in IBCT than in TBCT. Finally, there was evidence of greater stability during follow-up in IBCT than in TBCT couples. There was little change in individual functioning over follow-up, but when change occurred it was strongly related to change in marital satisfaction. Given that this sample was selected for its significant and chronic distress, the data are encouraging about the long-term impact of behavioral couple therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family preservation using multisystemic therapy: An effective alternative to incarcerating serious juvenile offenders.

Multisystemic therapy (MST) delivered through a community mental health center was compared with usual services delivered by a Department of Youth Services in the treatment of 84 serious juvenile offenders and their multiproblem families. Offenders were assigned randomly to treatment conditions. Pretreatment and posttreatment assessment batteries evaluating family relations, peer relations, symptomatology, social competence, and self-reported delinquency were completed by the youth and a parent, and archival records were searched at 59 wks postreferral to obtain data on rearrest and incarceration. In comparison with youths who received usual services, youths who received MST had fewer arrests and self-reported offenses and spent an average of 10 fewer weeks incarcerated. In addition, families in the MST condition reported increased family cohesion and decreased youth aggression in peer relations. The relative effectiveness of MST was neither moderated by demographic characteristics nor mediated by psychosocial variables. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multisystemic therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination

The effects of multisystemic therapy (MST) in treating violent and chronic juvenile offenders and their families in the absence of ongoing treatment fidelity checks were examined. Across 2 public sector mental health sites, 155 youths and their families were randomly assigned to MST versus usual juvenile justice services. Although MST improved adolescent symptomology at posttreatment and decreased incarceration by 47% at a 1.7-year follow-up, findings for decreased criminal activity were not as favorable as observed on other recent trials of MST. Analyses of parent, adolescent, and therapist reports of MST treatment adherence, however, indicated that outcomes were substantially better in cases where treatment adherence ratings were high. These results highlight the importance of maintaining treatment fidelity when disseminating complex family-based services to community settings.     

The transportability of multisystemic therapy to Sweden: Short-term results from a randomized trial of conduct-disordered youths.

This randomized clinical trial assessed the effectiveness of multisystemic therapy (MST) for 156 youths who met the diagnostic criteria for conduct disorder. Sweden's 3 largest cities and 1 small town served as the recruiting area for the study. A mixed factorial design was used, with random allocation between MST and treatment as usual groups. Assessments were conducted at intake and 7 months after referral. With an intention-to-treat approach, results from multiagent and multimethod assessment batteries showed a general decrease in psychiatric problems and antisocial behaviors among participants across treatments. There were no significant differences in treatment effects between the 2 groups. The lack of treatment effect did not appear to be caused by site differences or variations in program maturity. MST treatment fidelity was lower than that of other studies, although not clearly related to treatment outcomes in this study. The results are discussed in terms of differences between Sweden and the United States. One difference is the way in which young offenders are processed (a child welfare approach vs. a juvenile justice system approach). Sociodemographic differences (e.g., rates of poverty, crime, and substance abuse) between the 2 countries may also have moderating effects on the rates of rehabilitation among young offenders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized trial of treatment for children with sexual behavior problems: Ten-year follow-up.

This study prospectively follows 135 children 5-12 years of age with sexual behavior problems from a randomized trial comparing a 12-session group cognitive-behavioral therapy (CBT) with group play therapy and follows 156 general clinic children with nonsexual behavior problems. Ten-year follow-up data on future juvenile and adult arrests and child welfare perpetration reports were collected. The CBT group had significantly fewer future sex offenses than the play therapy group (2% vs. 10%) and did not differ from the general clinic comparison (3%), supporting the use of short-term CBT. There were no group differences in nonsexual offenses (21%). The findings do not support assumptions about persistent or difficult to modify risk and raise questions about policies and practices founded on this assumption. (PsycINFO Database Record (c) 2010 APA, all rights reserved)