Reducing the risk of criminal exploitation using multi-systemic therapy (the RESET Study): study protocol for a feasibility study and process evaluation

BACKGROUND

Child criminal exploitation is a form of child abuse that poses a serious risk to the welfare, safety, and wellbeing of young people. Multisystemic therapy (MST) is an intensive family and community-based intervention for young people with anti-social behavioral problems, many of whom will be at risk of criminal exploitation. This protocol describes a pilot feasibility study and process evaluation, designed to examine MST for children at risk of criminal exploitation.

METHODS

This pilot feasibility study and process evaluation involves two phases with associated subphases: phase 1.1 involved the collaborative refinement of the logic model adapting MST for children at risk of criminal exploitation; phase 1.2 involved pre-pilot interviews with MST therapists, families, and young people; phase 2.1 is a pilot modeling study of MST for children at risk of criminal exploitation, and; Phase 2.2 is a process evaluation that will involve interviewing stakeholders, MST therapists and employees, families, and young people. The dataset for the process evaluation will include questionnaires completed by parents and young people at baseline, mid-treatment, end of treatment, and 6 months after treatment. We will supplement these data with participant-level data linkage from MST sites and services.

RESULTS

Accrual to the pilot stage of this project opened on 6th August 2021 and is due to close on 31st May 2022. We aim to publish the results of this feasibility study and process evaluation in 2023.

CONCLUSIONS

The results of this feasibility study and process evaluation will inform the decision as to whether it is advisable to progress to a pilot clinical trial of MST for children at risk of criminal exploitation.

TRIAL REGISTRATION

Trial registration: ISRCTN registry, ISRCTN16164816 on 25th January 2021- https://doi.org/10.1186/ISRCTN16164816 .

Higher treatment focus diffusion in Multisystemic Therapy is associated with less functional improvement over the course of treatment

PURPOSE

Treatment focus diffusion (TFD), dividing focus across multiple concerns during treatment, is common in public mental health care and differs from the more narrowly focused empirically supported treatments for youth reported in the literature. The present study examined whether and to what extent TFD is associated with youth functional improvement over the course of therapy.

METHOD

This study utilized multi-level modeling techniques to analyze 12 consecutive years of standardized routine clinical service data from youth receiving treatment in one of two intensive in-home service settings: (a) Multisystemic Therapy (MST; n = 776 youths, 99 therapists), an implemented evidence-based treatment based on ecological theories of behavior in which therapists work with the multiple systems a youth interacts with (school, community, family), and (b) a standards-based service (n = 1854 youth, 413 therapists). Both service settings operate in the context of a publicly funded mental health care system which serves youth and families who are typically from underserved and low-income backgrounds. Majority of youth in this sample identified as multi-ethnic and male, and they, on average, were approximately 13 years old with three co-occurring diagnoses.

RESULTS

A significant TFD by service format interaction on youth functional improvement (alone and in the overall model) and follow up simple effects indicated that higher TFD was associated with significantly poorer outcomes in MST. The parameter estimate for TFD on functional improvement in the standards-based service format was in the same direction, but not statistically significant.

CONCLUSION

Our findings suggest that maintaining a narrower treatment focus might be beneficial to clients, particularly in implemented evidence-based treatments. Likewise, TFD could be a helpful case monitoring tool for clinicians, supervisors, and systems leaders when reviewing intensive-in-home cases.

Multisystemic Therapy - Building Stronger Families (MST-BSF): Substance misuse, child neglect, and parenting outcomes from an 18-month randomized effectiveness trial

BACKGROUND

Parental substance misuse impacts millions of children globally and is a major determinant of repeat maltreatment and out-of-home placement. There is little published research on family-based, comprehensive treatment models that simultaneously address parental substance misuse and child maltreatment.

OBJECTIVE

This study reports outcomes from a randomized clinical trial examining the effectiveness of the Multisystemic Therapy - Building Stronger Families (MST-BSF) treatment model with families involved with Child Protective Services due to physical abuse and/or neglect plus parental substance misuse.

PARTICIPANTS AND SETTING

Ninety-eight families who had an open case with Child Protective Services in two areas of the state of Connecticut participated.

METHOD

Families referred by the Connecticut Department of Children and Families were randomly assigned to MST-BSF or Comprehensive Community Treatment (CCT). Both interventions were delivered by community-based therapists. Outcomes were measured across 5 assessments extending 18 months post-baseline.

RESULTS

Intent-to-treat analyses showed that MST-BSF was significantly more effective than CCT in reducing parent self-reported alcohol and opiate use and in improving child-reported neglectful parenting. Although means were in predicted directions, new incidents of abuse across 18 months did not differ between groups. The study features high recruitment and engagement rates for a population experiencing multiple involvements with child protection.

CONCLUSION

The outcomes of this study support the effectiveness of MST-BSF, an intensive family- and ecologically- based treatment, for significantly reducing parental alcohol and opiate misuse and child neglect. These findings help in our understanding of how best to address the understudied issue of interventions for child neglect.

Identification of Multisystemic Therapy (MST) Subgroups with Distinct Trajectories on Ultimate Outcomes in Norway

The effect of Multisystemic Therapy (MST) treatment for serious behavior problems among adolescents has been established through multiple studies. However, variations across individuals should also be examined to better understand how MST works or for whom. In this study, we explored and identified subgroups of youth with serious problems in Norway regarding their responses to MST in terms of ultimate MST outcomes (e.g., living at home, abstaining from violence) over time. We further explored whether immigrant background, in addition to gender and age of the youth at intake, predicted belonging to the subgroups. Data came from 1674 adolescents (Mean_Age = 14.55, SD_Age = 1.58; 60.7% boys) and their families referred to MST treatment by the municipal Child Welfare Services for serious and persistent antisocial behavior. The outcomes were assessed at five time-points from intake to 18-months after discharge for youth and families who completed the treatment. Latent class growth analyses revealed heterogeneous trajectories regarding youths’ responses to MST. Results indicated a high and sustained degree of improvement across the ultimate outcomes for the vast majority of the youths. However, there was still variation in the groups, with improvement and deterioration trajectories for various outcomes. Most of these trajectories were predicted by gender and youth’s age at intake, but not by immigrant status. Not every youth-at-risk responds similarly to MST, and more studies examining heterogeneity will help us to identify factors to be targeted to better tailor the MST interventions for youth with serious problems.

Considerations for minority ethnic young people in multisystemic therapy

Research has indicated that multisystemic therapy (MST) is an effective treatment for youth with antisocial behaviours (Painter & Scannapieco, 2009). This qualitative study explored minority ethnic young peoples' experiences of MST, focusing on their understanding of their presenting difficulties and aspects of the intervention which facilitated or hindered engagement and change. Seven semi-structured interviews were conducted with London-based young people who had taken part in MST. A constructivist version of grounded theory analysis was employed. Culture-specific theoretical codes emerged; understanding the family culture and the practitioner acting as a cultural broker, consideration of acculturation differences within the family, exploring the young person's cultural identity and reflecting on cultural differences in the therapeutic relationship. Findings suggest potential advances to MST practice to meet the needs of minority ethnic young people, including the importance of appropriate training and supervision, sensitively working with salient cultural issues such as the impact of acculturation, and consideration of the role of therapist ethnicity and culture.

The Potential of Pay-for-Success as a Financing Strategy for Evidence-Based Practices: An Illustration with Multisystemic Therapy

There is a critical need to identify strategies for financing the implementation of evidence-based practices. We illustrate the potential of pay-for-success financing (PFS)-a strategy in which private investors fund implementation and receive a return on investment from a government payer-using multisystemic therapy as an example. We argue that standard multisystemic therapy (for serious juvenile offenders) and several of its adaptations (for other complex behavioral problems in youth) would be good candidates for PFS in the right contexts. Despite some challenges for policymakers and administrators, PFS has significant potential as a financing strategy for evidence-based practices.

Placement and Delinquency Outcomes Among System-Involved Youth Referred to Multisystemic Therapy: A Propensity Score Matching Analysis

Multisystemic therapy (MST) was developed to help youth with serious social, emotional, and behavioral problems. Research on the efficacy and effectiveness of MST has shown positive outcomes in different domains of development and functioning among various populations of youth. Nonetheless, even with a large body of literature investigating the treatment effects of MST, few studies have focused on the effectiveness of MST through large-scale dissemination efforts. Utilizing a large sample of youth involved in a statewide dissemination of MST (n = 740; 43% females; 14% Black; 29% Hispanic; 49% White; Mage = 14.9 years), propensity score matching was employed to account for baseline differences between the treatment (n = 577) and comparison (n = 163) groups. Treatment effects were examined based on three outcomes: out-of-home placement, adjudication, and placement in a juvenile training school over a 6-year period. Significant group differences remained after adjusting for baseline differences, with youth who received MST experiencing better outcomes in offending rates than youth who did not have an opportunity to complete MST due to non-clinical or administrative reasons. Survival analyses revealed rates of all three outcomes were approximately 40% lower among the treatment group. Overall, this study adds to the body of literature supporting the long-term effectiveness of MST in reducing offending among high-risk youth. The findings underscore the potential benefits of taking evidence-based programs such as MST to scale to improve the well-being and functioning of high-risk youth. However, strategies to effectively deliver the program in mental health service settings, and to address the specific needs of high-risk youth are necessary.

Efficacy of multisystemic therapy in youths aged 10-17 with severe antisocial behaviour and emotional disorders: systematic review

BACKGROUND

Antisocial behaviour and conduct disorders are the most common behavioural and mental health problems in children and young people globally. An efficacious intervention is needed to manage these antisocial behaviours that have costly consequences. Multisystemic Therapy (MST), an intensive home-based intervention for youths with psychosocial and behavioural problems, is recommended under National Institute for Health and Clinical Excellence guidelines for conduct disorder. However, reviews on the efficacy of MST are mixed.

AIM

To review randomised controlled trials (RCTs) reporting efficacy of MST among youths presenting with antisocial behaviour and emotional disorder respectively.

METHOD

A systematic map term to subject heading search was conducted in PsycINFO, Embase, and Ovid Medline databases for articles up to November 2015. RCTs comparing MST vs.treatment as usual (TAU) in youths presenting with antisocial behaviour and emotional disorder were included.

RESULTS

12 RCTs (n = 1425) reported efficacy of MST vs. TAU in youths presenting with antisocial behaviour and emotional disorder. Clinically significant treatment effects of MST showed a reduction of antisocial behaviour which includes delinquency. MST, vs. psychiatric hospitalisation, was associated with a reduction of suicidal attempts in youths presenting with psychiatric emergencies. 4 studies showed that MST was less costly than TAU in the short term, with further analysis required for long-term cost-effectiveness.

CONCLUSION

MST is an efficacious intervention for severe antisocial behaviours in reduction of delinquency and should be included in clinical practices. MST was shown to have a positive effect on emotional disorder but further research is needed to evaluate the efficacy of MST with emotional disorder. Further analysis is required to assess the services utilized for long-term cost effectiveness.

Predictive validity of an observer-rated adherence protocol for multisystemic therapy with juvenile drug offenders

OBJECTIVE

Multisystemic therapy (MST) is perhaps the best validated treatment for youth who engage in serious and chronic antisocial behavior (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009). Despite evidence suggesting that high treatment adherence is needed to achieve optimal MST outcomes, this research is limited because past studies have relied on adherence reports derived solely from treatment participants (i.e., caregivers, youth, and therapists). To address this gap in the literature, the present study assessed the reliability and predictive validity of an observational protocol for rating adherence to MST.

METHOD

The sample was drawn from a randomized clinical trial of juvenile drug offenders (77.5% male, 65% African American) referred to one of four treatment conditions (Henggeler et al., 2006). Audiotaped sessions of youth and their families were selected from the first month of MST and trained undergraduate students independently rated therapist adherence to the nine MST treatment principles. We assessed the validity of MST adherence in predicting outcomes at post-recruitment and 12-month follow-up.

RESULTS

Good interrater reliability (ICC=0.642) was found across all raters for our composite index of adherence. High adherence to MST during the first month of therapy predicted decreases in externalizing behavior at post-recruitment and decreases in youth alcohol consumption at 12-month follow-up.

CONCLUSIONS

These results provide independent support for the link between treatment fidelity and behavioral outcomes in the context of MST. Further, this study demonstrates the feasibility of using novice, undergraduate judges to reliably code therapist adherence.

Multisystemic Therapy(®) : Clinical Overview, Outcomes, and Implementation Research

Multisystemic therapy (MST) is an evidence-based treatment originally developed for youth with serious antisocial behavior who are at high risk for out-of-home placement and their families; and subsequently adapted to address other challenging clinical problems experience by youths and their families. The social-ecological theoretical framework of MST is presented as well as its home-based model of treatment delivery, defining clinical intervention strategies, and ongoing quality assurance/quality improvement system. With more than 100 peer-reviewed outcome and implementation journal articles published as of January 2016, the majority by independent investigators, MST is one of the most extensively evaluated family based treatments. Outcome research has yielded almost uniformly favorable results for youths and families, and implementation research has demonstrated the importance of treatment and program fidelity in achieving such outcomes.

Multisystemic Therapy for Externalizing Youth

Externalizing problems are multidetermined and related to individual, family, peer, school, and community risk factors. Multisystemic therapy (MST) was originally developed to address these risk factors among youth with serious conduct problems who are at-risk for out-of-home placement. Several decades of research have established MST as an evidence-based intervention for adolescents with serious clinical problems, including serious offending, delinquency, substance abuse, and parental physical abuse and neglect. This article presents an overview of the clinical procedures and evidence base of MST for externalizing problems as well as 2 adaptations: MST for Substance Abuse and MST for Child Abuse and Neglect.

Predictors of Therapist Adherence and Emotional Bond in Multisystemic Therapy: Testing Ethnicity as a Moderator

This study examined the interaction between problem severity and race\ethnicity as a predictor of therapist adherence and family-therapist emotional bond. Data for this study came from a longitudinal evaluation of Multisystemic Therapy (MST) provided by licensed MST provider organizations in community settings. Outcome variables included mid-treatment levels of caregiver report of therapist adherence, changes in caregiver report of therapist adherence over the course of treatment, and overall levels of caregiver-therapist and youth-therapist emotional bond. Hypothesized predictors included race\ethnicity and levels of poly-substance use, externalizing behavior, and youth self-report of delinquency early in treatment as well as pre-treatment number of arrests. Participants were 185 adolescents (M age = 15.35, SD = 1.29) and their caregivers. Of the participating youth, 48 % self-identified as Caucasian, 20 % as African-American, 28 % as Hispanic\Latino, and 4 % as "other." Two-level Hierarchical Linear Modeling analyses revealed that for Caucasian youth, lower rates of self-reported delinquency were associated with greater increases in caregiver report of therapist adherence over the course of MST. For His-panic\Latino caregivers, higher externalizing behavior and poly-substance use were associated with reports of lower therapist adherence at mid-treatment and poorer overall levels of emotional bonding with therapists. In contrast, for African-American participants, higher levels of youth externalizing behavior and poly-substance use were associated with higher overall levels of caregiver and youth report of emotional bonding with therapists, respectively. Results provide evidence that race\ethnicity interacts with problem severity in predicting therapist adherence and family-therapist emotional bond within real-world practice settings and suggest possible therapeutic process differences across race.

Multisystemic Therapy (MST) for Youth Offending, Psychiatric Disorder and Substance Abuse: Case Examples from a UK MST Team

BACKGROUND

  The paper illustrates the MST treatment model with three types of presenting problem in young people aged 14-15.

METHOD

  The MST model is described and then illustrated with detailed case material from a violent young person convicted of robbery, a young person with a history of serious self-harming behaviour and hospitalisation, and a young person persistently smoking cannabis.

RESULTS

  All three cases improved after the MST intervention despite disparate presenting problems that included re-offending, the elimination of self-harming behaviour and a significant reduction in the use of cannabis. The three young people were re-integrated into the education system.

CONCLUSION

  This case series illustrates the potential uses of the MST model in CAMHS although RCT data are needed to replicate the effectiveness of MST in the British context.