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

1. 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

2. 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.

3. 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

4. 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

5. 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.

6. STRUCTURE OF MST • Treatment targets serious juvenile offenders at high risk for out-of-home placement and their families • MST team includes 3-4 master’s 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

7. 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

8. 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

9. Referral Behavior MST Analytical Process Desired Outcomes of Family and Other Key Participants Overarching Goals Environment of Alignment and Engagement of Family and Key Participants MST Conceptualization of “Fit” Re-evaluate Prioritize Assessment of Advances & Barriers to Intervention Effectiveness Intermediary Goals Measure Do Intervention Implementation Intervention Development

10. PUBLISHED MST OUTCOMES 10 Randomized Trials and 1 Quasi-Experimental Trial Published (>1000 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

11. OVERVIEW OF MST OUTCOMES ASSOCIATED WITH: Criminal Behavior & Violence Adolescent Substance Abuse Adolescent Sexual Offending Mental Health Child Maltreatment

12. 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

13. Simpsonville, SC Project

14. Missouri Delinquency Project

15. 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

16. 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%)

17. MST 12-MONTH OUTCOMES FROM JUVENILE DRUG COURT RANDOMIZED TRIAL (N=161) 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)

18. MST OUTCOMES ASSOCIATED WITH ADOLESCENT SEXUAL OFFENDING • Study with N=16: 3 year rearrest data for sexual offending favoring MST (12.5% versus 75%) • Replication study with N=48: 8-year rearrest data for sexual offending favoring MST (12.5% versus 41.7%) • 66% decrease in days incarcerated • Effectiveness study underway in Chicago

19. 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 (N=36) replication study in Hawaii

20. 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

21. 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

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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 <www.mstinstitute.org> • Expert coding of audiotaped treatment sessions for adherence (research studies only)

30. 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

31. 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)

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. QUESTIONS OR MORE INFORMATION • Research Related: Scott W. Henggeler <henggesw@musc.edu> • Publication Requests: <musc.edu/fsrc> • Dissemination/Site Development: Marshall Swenson, 843 856-8226 <marshall.swenson@mstservices.com>