Effective Partnerships Between Juvenile Courts, Families and MST:

1. Effective Partnerships Between Juvenile Courts, Families and MST: Treating Adolescents with Behavioral Challenges in the Home, School and Community with Multisystemic Therapy, a Model Plus Evidence- Based Program Over 100 Years of Leadership in Social Justice

2. Presenters Maureen Kishna, MST Consultant / Program Developer Center for Innovative Practices (CIP) Begun Center for Violence Prevention Misty Hanson, Chief Probation Officer, Wayne County Juvenile Court Matt Kresic, CEO, Homes for Kids Lisa Cioffi, MST Program Manager and MST-PSB Supervisor, Child & Adolescent Behavioral Health

3. Questions the group has about MST?

4. Standard MST Teams in Ohio

5. MST in Ohio- Ask Jeff Spears and Judy Wood • CIP was created by the state Department of Mental Health in 2000 • A part of a state-wide MH initiative to promote best practices • Several Centers of Excellences (COE) created • CIP specifically for MST, initially • Only COE focused on youth and families

6. Multisystemic Therapy Overview Breaking the cycle of criminal behavior by keeping teens at home, in school and out of trouble

7. What is MST? • A community-based, family-driven treatment for antisocial/delinquent behavior in youth • Focuses on “Empowering” caregivers (parents) to solve current and future problems • MST’s “client” is the entire ecology of the youth - family, peers, school, neighborhood • Uses highly structured clinical supervision and quality assurance processes

8. Families as the Solution • MST focuses on families as the solution • Families are full collaborators in treatment planning and delivery with a focus on family members as the long-term change agents • Labeling families as “resistant” or “unmotivated” is not an option • MST has a strong track record of client engagement, retention, and satisfaction

9. 2014 MST Global Footprint Breaking the cycle of criminal behavior by keeping teens at home, in school and out of trouble

10. Worldwide Recognition

11. Causal Models of Delinquency and Drug Use: Common Findings of 50+ Years of Research Prior Delinquent Behavior Family Delinquent Behavior Delinquent Peers School Neighborhood/Community Context

12. Delinquency is a Complex Behavior • Common findings of 50+ years of research: delinquency and drug use are determined by multiple risk factors: • Family (low monitoring, high conflict, etc.) • Peer group (law-breaking peers, etc.) • School (dropout, low achievement, etc.) • Community ( supports,  transiency, etc.) • Individual (low verbal and social skills, etc.)

13. MST Theory of Change • Peers • Reduced Antisocial Behavior and Improved Functioning • Improved Family Functioning • MST • School • Community

14. How is MST Implemented? • Single therapist working intensively with 4 to 6 families at a time • Team of 2 to 4 therapists plus a supervisor • 24 hr/ 7 day/week team availability: on call system • 3 to 5 months is the typical treatment time (4 months on average across cases) • Work is done in the community, home, school, neighborhood: removes barriers to service access

15. How is MST Implemented? (Cont.) • MST staff deliver all treatment – typically no or few services are brokered/referred outside the MST team • Continuous focus on engagement and alignment with primary caregiver and other key stakeholders (e.g. probation, courts, children and family services, etc.) • MST staff must be able to have a “lead” clinical role, ensuring services are individualized to strengths and needs of each youth/family

16. Built in Services

17. Standard MST Referral Criteria (ages 12-17) Inclusionary Criteria Exclusionary Criteria Youth living independently Sex offending in the absence of other anti social behavior Youth with moderate to severe autism (difficulties with social communication, social interaction, and repetitive behaviors) Actively homicidal, suicidal or psychotic Youths whose psychiatric problems are the primary reason leading to referral, or who have severe and serious psychiatric problems • Youth at risk for placement due to anti-social or delinquent behaviors, including substance use • Youth involved with the juvenile justice system • Youth who have committed sexual offenses in conjunction with other anti- social behavior

18. Quality Assurance and Continuous Quality Improvement of MST Goal of MST Implementation: Obtain positive outcomes for MST youth and their families QA/QI Process: Training and ongoing support (orientation training, quarterly boosters, weekly expert consultation, weekly supervision) Organizational support for MST programs Implementation monitoring (measure adherence and outcomes, work sample reviews) Improve MST implementation as needed, using feedback from training, ongoing support, and measurement Multisystemic Therapy (MST) Overview

19. PIR Program Implementation Review and other reports MST QA/QI Overview Input/feedback via internet-based data collection Training/support, including MST manuals/materials Output to – Organization, Program Stakeholders and MST Coach Organizational Context MST Coach MST Expert/ Consultant MST Supervisor MST Therapist Youth/ Family SAM Supervisor Adherence Measure CAM Consultant Adherence Measure TAM Therapist Adherence Measure Output to – MST Coach Output to – MST Expert Output to – MSTSupervisor and MST Expert

20. 30+ Years of science Breaking the cycle of criminal behavior by keeping teens at home, in school and out of trouble

21. MST Ultimate Outcomes: 2015 MSTI Data Report Multisystemic Therapy (MST) Overview

22. Long-term Outcomes Breaking the cycle of criminal behavior by keeping teens at home, in school and out of trouble

23. Very Long-Term Outcomes Breaking the cycle of criminal behavior by keeping teens at home, in school and out of trouble

24. Common Questions about MST Key Points • MST & Court Collaboration • Youth at Imminent Risk of Placement • Aggression & Safety planning • Runaway = Monitoring & Retrieval • Substance Use

25. MST & Court Collaboration • If the court desires, MST therapists will send weekly case reports to involved court counselors and judges • MST therapists can be present for each court hearing and will prepare statements to provide to the judge at the time of the hearing if desired by the court • MST therapists and families will work together to develop safety and monitoring plans to address court concerns of community safety

26. Youth at Imminent Risk of Placement: Aggression • MST therapist and family develop and implement extensive safety plan to address physical aggression • Enlist local police officers and court counselors to assist with safety protocols • Help adults develop de-escalation skills to manage behaviors safely • Address all relevant systems in safety plans, including school, community, and home • Assess safety plans regularly to determine if changes/adjustments are needed • Share safety plans with court counselors and judges as requested

27. Youth at Imminent Risk of Placement: Runaway • MST therapist and family develop and implement an extensive monitoring & retrieval plan • Develop plans using formal and informal supports to find and bring the youth home as quickly as possible. • Identify troublesome peers and limit or eliminate access • Help parents develop relationships with peers’ parents to strengthen community supports vs. relying on the legal system • Share plans with court counselors and judges as requested

28. Youth at Imminent Risk of Placement: Substance Use • MST therapist and family develop and implement an extensive monitoring & behavior plan • Identify negative peers and limit access • Engage the youth in pro-social activities • Conduct room searches and home drug testing • Providing rewards and consequences as indicated • Enlist family supports to carry out interventions • Utilization of Contingency Management interventions as clinically indicated (ABC assessment, Family Drug Management Planning, Drug refusal skills, incentives given by parents (sometimes funded by programs for results of caregiver-administered drug screens)

29. Why is MST Successful? • Treatment targets known causes of delinquency: family relations, peer relations, school performance, community factors • Treatment is family-driven and occurs in each youth’s natural environment • Significant energies are devoted to developing positive interagency relations • MST personnel are well trained and supported • Providers are accountable for outcomes • Continuous quality improvement occurs at all levels

30. System Cost Savings

31. System Cost Savings

32. State Cost Savings

33. New Mexico Medicaid Cost Savings • 66% reduction average charges to Medicaid= • $133.5 Million saved through reductions in Medicaid covered behavioral health claims and crime • 66% reduction in residential charges per month • $36.1 Million in reduced Medicaid expenses in two years • 77% reduction in inpatient charges per month • 52% reduction in outpatient charges per month

34. Cost Savings-Family Impact

35. 22 year follow up data

36. MST is a Model Plus Program

37. Cuyahoga County JC- MST and Residential Placement Evaluation 2017 Jeff Krestschmar, PhD and Ashley Bukach, MPH • 72 MST youth and 81 placement youth were included in analysis • Very few differences related to demographics & JC involvement between groups • MST youth were charged with fewer misdemeanors, felonies & violent crimes than placement youth • Cost of MST was substantially less than the cost of residential.

38. The Cost of MST and Residential-court data • The cost of residential treatment in 2017 per youth to the CCJC was an average of $33,181. • The cost of MST per youth to the CCJC is currently approximately $8,633. • The cost per youth fluctuates by the number of youth served. Serving more youth a year by a team or program drives down the program’s cost per youth.

39. MST Program in Wayne, Holmes Counties • BHJJ grant partners • Expanded well established MST program from more urban Stark County to these neighboring more rural counties • MST Provider Agency: Crisis Intervention and Recovery Center of Stark County---now *Child and Adolescent Behavioral Health • Celebrating over 20 years of providing MST! • Site of first independent replication study of MST: • Funded by the Ohio Office of Criminal Justice Services -Jane Timmons Mitchell, PhD, Monica B. Bender, Maureen A. Kishna and Clare C. Mitchell

40. MST Program in Wayne and Holmes Counties • Local Program Champions: • Mental Health & Recovery Board of Wayne & Holmes Counties • Wayne and Holmes County Juvenile Courts • Wayne County Chief Probation Officer Misty Hanson • Holmes County Chief Probation Officer Dave Williams • Wayne County Children’s Services

41. Average OYAS Scores • Intake: Average is 13= Moderate • Discharge: Average is 9= Low

42. MST in Wayne County, Greater Wooster area • Total Participants= 65 youth

43. MST in Wayne County • Total charges pre-MST: 263 (AVERAGE= 4.24 PER YOUTH) • New charges during MST: 30 (AVERAGE= 0.48 PER YOUTH) • New charges post-MST: 76 (AVERAGE= 1.23 PER YOUTH) *Court stats show that simply participating in MST no matter the outcome (successful or unsuccessful) decreased charges.

44. MST in Wayne County • Court Placements: Total new youth placed outside of the home by the Juvenile Court • 2013 = 10 (MST BEGAN LATE 2013) • 2014 = 3 • 2015 = 1 • 2016 = 2 • 2017 = 4 • 2018 = 3 • Difference from last full year prior to MST to now is a 44.12% reduction in total out of home placements

45. MST in Wayne County • Of the 50 youth that successfully completed MST, 15 would have most likely gone to placement if MST was not available at the time they began the program. On average, all youth placed outside of the home in residential settings in Wayne County are out of the home for around 17 months (510 days) at an average cost of $233 per day. • 15 youth x $118,830 per youth = $1,782,450 -potential cost savings since the inception of MST in Wayne Co.

46. Wayne County BHJJ Data • Pre-MST: • Common DSM diagnoses included ADHD, ODD, cannabis disorders, and depressive disorders. • 86% of females talked about suicide and 43% attempted it • MST led to a 78% reduction in risk for out of home placement • 83% of youth completed treatment successfully • No youth were sent to an ODYS institution following services • Treatment led to significant improvements in problem severity and functioning • Suspensions/expulsions were reduced by 74% during treatment • Youth reported significant reductions in substance abuse

47. Holmes County MST • 47 total families took part in MST According to BHJJ Data: • Pre- MST: Over 60% of the females were victims of sexual abuse. • 95% of youth completed treatment successfully • BHJJ led to a 61% reduction in risk for out of home placement • Youth reported significant reductions in trauma symptoms and substance abuse • Treatment led to significant improvements in problem severity and functioning • Grades improved and school suspensions/expulsions were greatly reduced • No youth were sent to an ODYS institution following services

48. System Changes • One of the key benefits Chief P.O. Dave Williams noted is that the dosage of probation contact can be reduced with a youth in MST • Probation gets to take a back seat • Judge puts responsibility back on the family • Asks family what plans they developed with MST to address the issues that bring them in front of the bench • Everyone knows they had MST and asks them to follow what they learned • Collaboration between JC and CSB

49. System Changes Continued • Court wants to try MST before placement • Defense attorneys ask for MST • Took a couple of cases for the court to trust the model and see how community safety concerns were addressed collaboratively • Built into grant money for prosocial activities, which also gives worn out caregivers much needed respite • Wayne County, after success with Standard MST got MST-PSB • They only have the caseload of 1 MST Therapist serving each county. Couldn't do it well without partnering. • With decreased filings at JC, flexibility is needed: • MST Therapists working cross-counties to serve needs and keep caseloads in range • Referrals from CSB funneling through the court

50. Wayne County MST Case Highest Priority Referral Behaviors: • Leaving without Permission: 2-3 times weekly; does not tell parents where she is going, sneaks out at night, ran away for 3 days • Physical Aggression/Poor school behaviors: Multiple in-school and out for school suspensions • bit and scratched school staff/charged with felony for assault • Suicidal Ideation: Multiple providers deemed this to be behavioral and functional • 1-2 X’s monthly; occurs at home and school when she is being held accountable or upset • Past Suicide Attempts: occurred two times when held accountable at school and home • Self-harm: 1-2 X’s monthly; when upset