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.     

Effectiveness of multidimensional family therapy with higher severity substance-abusing adolescents: Report from two randomized controlled trials.

Objective: We used growth mixture modeling to examine heterogeneity in treatment response in a secondary analysis of 2 randomized controlled trials testing multidimensional family therapy (MDFT), an established evidence-based therapy for adolescent drug abuse and delinquency. Method: The first study compared 2 evidence-based adolescent substance abuse treatments: individually focused cognitive–behavioral therapy and MDFT in a sample of 224 urban, low-income, ethnic minority youths (average age = 15 years, 81% male, 72% African American). The second compared a cross-systems version of MDFT (MDFT—detention to community) with enhanced services as usual for 154 youths, also primarily urban and ethnic minority (average age = 15 years, 83% male, 61% African American, 22% Latino), who were incarcerated in detention facilities. Results: In both studies, the analyses supported the distinctiveness of 2 classes of substance use severity, characterized primarily by adolescents with higher and lower initial severity; the higher severity class also had greater psychiatric comorbidity. In each study, the 2 treatments showed similar effects in the classes with lower severity/frequency of substance use and fewer comorbid diagnoses. Further, in both studies, MDFT was more effective for the classes with greater overall substance use severity and frequency and more comorbid diagnoses. Conclusions: Results indicate that for youths with more severe drug use and greater psychiatric comorbidity, MDFT produced superior treatment outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial.

Despite the serious and costly problems presented by juvenile sexual offenders, rigorous tests of promising interventions have rarely been conducted. This study presents a community-based effectiveness trial comparing multisystemic therapy (MST) adapted for juvenile sexual offenders with services that are typical of those provided to juvenile sexual offenders in the United States. Youth were randomized to MST (n = 67) or treatment as usual for juvenile sexual offenders (TAU-JSO; n = 60). Outcomes through 12 months postrecruitment were assessed for problem sexual behavior, delinquency, substance use, mental health functioning, and out-of-home placements. Relative to youth who received TAU-JSO, youth in the MST condition evidenced significant reductions in sexual behavior problems, delinquency, substance use, externalizing symptoms, and out-of-home placements. The findings suggest that family- and community-based interventions, especially those with an established evidence-base in treating adolescent antisocial behavior, hold considerable promise in meeting the clinical needs of juvenile sexual 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)     

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)     

Associations Among Childhood Trauma, Adolescent Problem Behaviors, and Adverse Adult Outcomes in Substance-Abusing Women Offenders.

This article explores relationships among exposure to childhood abuse and traumatic events, adolescent conduct problems and substance abuse, and adult psychological distress and criminal behaviors in a sample of substance-abusing women offenders (N = 440). Latent variable structural equation models revealed direct relationships between several childhood traumatic events and greater adolescent conduct problems and substance abuse. Conduct problems predicted more adult criminal behavior, and adolescent substance abuse predicted higher levels of current psychological distress. There were direct relationships between several types of traumatic events and current psychological distress and between traumatic events and specific criminal behaviors. Ethnic differences were also found, suggesting different pathways to criminal behavior. The findings underscore the need to provide trauma-related services for substance-abusing women offenders. (PsycINFO Database Record (c) 2010 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)     

Mediators of change for multisystemic therapy with juvenile sexual offenders.

The mediators of favorable multisystemic therapy (MST) outcomes achieved at 12 months postrecruitment were examined within the context of a randomized effectiveness trial with 127 juvenile sexual offenders and their caregivers. Outcome measures assessed youth delinquency, substance use, externalizing symptoms, and deviant sexual interest/risk behaviors; hypothesized mediators included measures of parenting and peer relations. Data were collected at pretreatment, 6 months postrecruitment, and 12 months postrecruitment. Consistent with the MST theory of change and the small extant literature in this area of research, analyses showed that favorable MST effects on youth antisocial behavior and deviant sexual interest/risk behaviors were mediated by increased caregiver follow-through on discipline practices as well as decreased caregiver disapproval of and concern about the youth’s bad friends during the follow-up. These findings have important implications for the community-based treatment of juvenile sexual offenders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Linking Session Focus to Treatment Outcome in Evidence-Based Treatments for Adolescent Substance Abuse.

The relation between specific therapy techniques and treatment outcome was examined for 2 empirically supported treatments for adolescent substance abuse: individual cognitive-behavioral therapy and multidimensional family therapy. Participants were 51 inner-city, substance-abusing adolescents receiving outpatient psychotherapy within a larger randomized trial. One session per case was evaluated using a 17-item observational measure of model-specific techniques and therapeutic foci. Exploratory factor analysis identified 2 subscales, Adolescent Focus and Family Focus, with strong interrater reliability and internal consistency. Process-outcome analyses revealed that family focus, but not adolescent focus, predicted posttreatment improvement in drug use, externalizing symptoms, and internalizing symptoms within both study conditions. Implications for the implementation and dissemination of individual-based and family-based approaches for adolescent drug use are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of parental alcoholism to early adolescent substance use: A test of three mediating mechanisms.

Assessed 3 hypothesized mediating mechanisms underlying the relation between parental alcoholism and adolescent substance use. Using structural equation modeling, data obtained from a large community sample of adolescent children of alcoholics and a demographically matched comparison group were analyzed. Results suggested that parental alcoholism influenced adolescent substance use through stress and negative affect pathways, through decreased parental monitoring, and through increased temperamental emotionality (which was associated with heightened negative affect). Both negative affect and impaired parental monitoring were associated with adolescents' membership in a peer network that supported drug use behavior. The data did not support a link between parental alcoholism and temperamental sociability. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mechanisms of change in multisystemic therapy: Reducing delinquent behavior through therapist adherence and improved family and peer functioning.

The mechanisms through which multisystemic therapy (MST) decreased delinquent behavior were assessed in 2 samples of juvenile offenders. Sample 1 included serious offenders who were predominantly rural, male, and African American. Sample 2 included substance-abusing offenders who were predominantly urban, male, and Caucasian. Therapist adherence to the MST protocol (based on multiple respondents) was associated with improved family relations (family cohesion, family functioning, and parent monitoring) and decreased delinquent peer affiliation, which, in turn, were associated with decreased delinquent behavior. Furthermore, changes in family relations and delinquent peer affiliation mediated the relationship between caregiver-rated adherence and reductions in delinquent behavior. The findings highlight the importance of identifying central change mechanisms in determining how complex treatments such as MST contribute to ultimate outcomes. (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)     

The efficacy of structural ecosystems therapy with drug-abusing/dependent African American and Hispanic American adolescents.

Many family therapies for adolescent drug use include ecological interventions. The purpose of this randomized clinical trial was to establish whether ecological interventions contribute to the impact of family therapy above and beyond the contributions of family process-only interventions. A family-based ecological approach, structural ecosystems therapy (SET), was compared with family process-only condition (FAM) and community services control (CS). One hundred ninety substance-abusing or dependent African American and Hispanic adolescents were randomized to SET, FAM, or CS. Follow-up assessments were conducted at 3, 6, 12, and 18 months postrandomization. SET was significantly more efficacious than FAM and CS in reducing adolescent drug use. However, these improvements were limited to Hispanic adolescents. The study demonstrates the importance of investigating changes in adolescent drug use as a result of treatment condition across more than 1 racial/ethnic group. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trajectories of family management practices and early adolescent behavioral outcomes.

Stage–environment fit theory was used to examine the reciprocal lagged relations between family management practices and early adolescent problem behavior during the middle school years. In addition, the potential moderating roles of family structure and of gender were explored. Hierarchical linear modeling was used to describe patterns of growth in family management practices and adolescents' behavioral outcomes and to detect predictors of interindividual differences in initial status and rate of change. The sample comprised approximately 1,000 adolescents between ages 11 years and 15 years. The results indicated that adolescents' antisocial behaviors and substance use increased and their positive behavioral engagement decreased over time. As adolescent age increased, parental knowledge of their adolescent's activities decreased, as did parental rule making and support. The level and rate of change in family management and adolescent behavioral outcomes varied by family structure and by gender. Reciprocal longitudinal associations between parenting practices and adolescent problem behavior were found. Specifically, parenting practices predicted subsequent adolescent behavior, and adolescent behavior predicted subsequent parenting practices. In addition, parental warmth moderated the effects of parental knowledge and rule making on adolescent antisocial behavior and substance use over time. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Treatment techniques and outcomes in multidimensional family therapy for adolescent behavior problems.

The link between treatment techniques and long-term treatment outcome was examined in an empirically supported family-based treatment for adolescent drug abuse. Observational ratings of therapist interventions were used to predict outcomes at 6 and 12 months posttreatment for 63 families receiving multidimensional family therapy. Greater use of in-session family-focused techniques predicted reduction in internalizing symptoms and improvement in family cohesion. Greater use of family-focused techniques also predicted reduced externalizing symptoms and family conflict, but only when adolescent focus was also high. In addition, greater use of adolescent-focused techniques predicted improvement in family cohesion and family conflict. Results suggest that both individual and multiperson interventions can exert an influential role in family-based therapy for clinically referred adolescents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Melatonin-induced T-helper cell hematopoietic cytokines resembling both interleukin-4 and dynorphin

The juvenile court of the future will be a viable, but changed, institution largely because of society's need to hold parents accountable for their children's well-being and youths accountable for their actions. The author describes three current trends in juvenile court which will continue to impact the court in the future. First, more jurisdictions will refine and streamline their court structures, either through better coordination or by creating unified family courts. This will result in better handling and supervision of multiple cases involving the same family. Second, the use of a wide variety of alternative dispute resolution techniques will grow, and the court will assume a monitoring and oversight function over these mediated agreements. Third, private and voluntary efforts will be utilized to assist the court in providing services to children and families, as well as to mobilize community-wide efforts on behalf of children. Ideally, the juvenile court of the future will place itself squarely in the community and work with others concerned about the well-being of children and families to provide an appropriate and meaningful response to each child who comes within the court's purview.     

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)     

Childhood Peer Rejection and Aggression as Predictors of Adolescent Girls' Externalizing and Health Risk Behaviors: A 6-Year Longitudinal Study.

This 6-year longitudinal study examined girls' peer-nominated social preference and aggression in childhood as predictors of self- and parent-reported externalizing symptoms, substance use (i.e.. cigarette, alcohol, and marijuana use), and sexual risk behavior in adolescence. Participants were 148 girls from diverse ethnic backgrounds, who were initially assessed in Grades 4-6 and again in Grades 10-12. Results supported a moderator model, indicating that social preference changed the nature of the association between childhood aggression and adolescent outcomes. When accompanied by peer rejection, aggressive behavior was moderately stable over time and significantly associated with adolescent girls' substance use and sexual risk behavior. However, under conditions of peer acceptance, no significant association between childhood aggression and adolescent outcomes emerged. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pregnancy rates among juvenile justice girls in two randomized controlled trials of multidimensional treatment foster care.

Preventing adolescent pregnancy is a national research priority that has had limited success. In the present study, the authors examined whether Multidimensional Treatment Foster Care (MTFC) relative to intervention services as usual (group care [GC]) decreased pregnancy rates among juvenile justice girls mandated to out-of-home care. Girls (13–17 years of age) with histories of criminal referrals (Mdn = 10) were randomly assigned to MTFC (n = 81) or GC (n = 85) as part of 2 randomized controlled trials. Pregnancy histories were assessed from baseline through 24 months. Fewer postbaseline pregnancies were reported for MTFC girls (26.9%) than for GC girls (46.9%)—an effect that remained significant after controlling for baseline criminal referrals, pregnancy history, and sexual activity. MTFC has previously been shown to decrease arrest and lock-up rates. The present findings support the long-term preventive effects of MTFC on adolescent girls’ pregnancy rates. Findings are consistent with the notion that programs that target delinquency by impacting general risk behavior pathways and contexts may more successfully prevent teen pregnancy than those that directly target sexual behaviors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Adolescent outcomes for hyperactive children: Perspectives on general and specific patterns of childhood risk for adolescent educational, social, and mental health problems.

Examined significant differences, if any, among adolescent outcomes for hyperactive children and examined early life contributions of biological and psychological characteristics, family environments, social relationships, cognitive and academic status, and school behavior, along with hyperactivity, in explaining each of several outcomes. The Ss were classified on the basis of social system definitions of hyperactivity as well as on the basis of pervasive attention deficit disorder with hyperactivity (ADDH) based on parent and teacher ratings. Outcome measures at ages 17 and 18 included data on educational status, conduct problems, mental health disorders, and substance use. Regardless of the definition used, hyperactive children had significantly poorer educational outcomes and a greater extent of conduct disorders than their age peer controls. Regression analyses supported the inference that early biological factors, as well as the child's early health and temperament, predispose for adolescent mental health outcomes of depression, aggressive and nonaggressive conduct disorders, and hospitalization for psychological treatment. Familial, social, and cognitive factors had greater contributory potential in explaining educational outcomes, substance use, and conduct problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)