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Multisystemic Therapy® (MST®)

Blueprints Program Rating: Model Plus

A juvenile crime prevention program to enhance parenting skills and provide intensive family therapy to troubled teens and delinquent teens that empower youth to cope with the family, peer, school, and neighborhood problems they encounter - in ways that promote prosocial behavior while decreasing youth violence and other antisocial behaviors.

  • Scott W. Henggeler, Ph.D.
  • Medical University of South Carolina
  • Department of Psychiatry and Behavioral Sciences
  • Family Services Research Center
  • 171 Ashley Avenue
  • Charleston, SC 29425-0742
  • (843) 876-1800
  • (843) 876-1808
  • henggesw@musc.edu
  • Close Relationships with Parents
  • Conduct Problems
  • Delinquency and Criminal Behavior
  • Externalizing
  • Illicit Drug Use
  • Internalizing
  • Mental Health - Other
  • Positive Social/Prosocial Behavior
  • Prosocial with Peers
  • Violence

    Program Type

    • Family Therapy
    • Juvenile Justice, Other

    Program Setting

    • Correctional Facility
    • Home
    • Mental Health/Treatment Center
    • School
    • Social Services
    • Transitional Between Contexts

    Continuum of Intervention

    • Indicated Prevention (Early Symptoms of Problem)

    A juvenile crime prevention program to enhance parenting skills and provide intensive family therapy to troubled teens and delinquent teens that empower youth to cope with the family, peer, school, and neighborhood problems they encounter - in ways that promote prosocial behavior while decreasing youth violence and other antisocial behaviors.

      Population Demographics

      MST® targets chronic, serious, violent, and substance abusing juvenile offenders ages 12-17.

      Age

      • Early Adolescence (12-14) - Middle School
      • Late Adolescence (15-18) - High School

      Gender

      • Male and Female

      Gender Specific Findings

      • Male
      • Female

      Race/Ethnicity

      • All Race/Ethnicity

      Race/Ethnicity Specific Findings

      • White
      • African American
      • Hispanic or Latino

      Race/Ethnicity/Gender Details

      In several studies, MST has been found effective for both genders. It has also been shown to be equally effective with youths of different age and ethnic backgrounds. Additionally, several studies included a majority sample of African Americans and one study (Fain et al., 2014) found the program to be more effective with Hispanics/Latinos than African Americans.

      Individual: Attributional bias and antisocial attitudes
      Family: Low warmth, high conflict, harsh and/or inconsistent discipline, low monitoring of youths whereabouts, parental problems, and low support
      Peer: Association with deviant peers
      School: Low family-school bonding, problems with academic and social performance
      Community: Transiency, disorganization, criminal subculture

      • Neighborhood/Community
      • Family
      • School
      • Peer
      • Individual
      Risk Factors
      • Individual: Early initiation of antisocial behavior, Early initiation of drug use, Rebelliousness, Substance use
      • Peer: Interaction with antisocial peers, Peer substance use
      • Family: Family conflict/violence*, Neglectful parenting, Parent history of mental health difficulties*, Parent stress, Parental attitudes favorable to antisocial behavior, Parental attitudes favorable to drug use, Poor family management*, Violent discipline
      • School: Low school commitment and attachment*, Poor academic performance
      • Neighborhood/Community: Community disorganization, Laws and norms favorable to drug use/crime, Low neighborhood attachment
      Protective Factors
      • Individual: Clear standards for behavior, Problem solving skills, Prosocial involvement*, Rewards for prosocial involvement, Skills for social interaction*
      • Peer: Interaction with prosocial peers*
      • Family: Attachment to parents, Non-violent discipline*, Opportunities for prosocial involvement with parents, Parent social support, Parental involvement in education, Rewards for prosocial involvement with parents
      • School: Opportunities for prosocial involvement in education, Rewards for prosocial involvement in school
      • Neighborhood/Community: Opportunities for prosocial involvement, Rewards for prosocial involvement

      *Risk/Protective Factor was significantly impacted by the program.

      See also: Multisystemic Therapy® (MST®) Logic Model (PDF)

      Multisystemic Therapy® (MST®) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behavior in juvenile offenders. The MST program seeks to improve the real-world functioning of youth by changing their natural settings - home, school, and neighborhood - in ways that promote prosocial behavior while decreasing antisocial behavior. Therapists work with youth and their families to address the known causes of delinquency on an individualized, yet comprehensive basis. By using the strengths in each system (family, peers, school, and neighborhood) to facilitate change, MST addresses the multiple factors known to be related to delinquency across the key systems within which youth are embedded. The extent of treatment varies by family according to clinical need. Therapists generally spend more time with families in the initial weeks (daily if needed) and gradually taper their time (to as infrequently as once a week) over the 3- to 5-month course of treatment.

      Multisystemic Therapy® (MST®) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behavior across key settings, or systems within which youth are embedded (family, peers, school, and neighborhood). Because MST emphasizes promoting behavior change in the youth's natural environment, the program aims to empower parents with the skills and resources needed to independently address the inevitable difficulties that arise in raising teenagers, and to empower youth to cope with the family, peer, school, and neighborhood problems they encounter.

      Within a context of support and skill building, the therapist places developmentally appropriate demands on adolescents and their families to reduce problem behavior. Initial therapy sessions identify the strengths and weaknesses of the adolescent, the family, and their transactions with extrafamilial systems (e.g., peers, friends, school, parental workplace). Problems identified by both family members and the therapist are explicitly targeted for change by using the strengths in each system to facilitate such change. Treatment approaches are derived from well-validated strategies such as strategic family therapy, structural family therapy, behavioral parent training, and cognitive behavioral therapy.

      While MST focuses on addressing the known causes of delinquency on an individualized comprehensive basis, several types of interventions are typically identified for serious juvenile offenders and their families. At the family level, MST interventions aim to remove barriers to effective parenting (e.g., parental substance abuse, parental psychopathology, low social support, high stress, and marital conflict), to enhance parenting competencies, and to promote affection and communication among family members. Interventions might include introducing systematic monitoring, reward, and discipline systems; prompting parents to communicate effectively with each other about adolescent problems; problem solving day-to-day conflicts; and developing social support networks. At the peer level, interventions frequently are designed to decrease affiliation with delinquent and drug-using peers and to increase affiliation with prosocial peers. Interventions in the school domain may focus on establishing positive lines of communication between parents and teachers, parental monitoring of the adolescent's school performance, and restructuring after-school hours to support academic efforts. Individual level interventions generally involve using cognitive behavior therapy to modify the individual's social perspective-taking skills, belief system, or motivational system, and encouraging the adolescent to deal assertively with negative peer pressure.

      A Master's-Level therapist, with a caseload of 4 to 6 families, provides most mental health services and coordinates access to other important services (e.g., medical, educational, and recreational). While the therapist is available to the family 24 hours a day, 7 days a week, the direct contact hours per family varies according to clinical need. Generally, the therapist spends more time with the family in the initial weeks of the program (daily if needed) and gradually tapers off (as infrequently as once a week) during a 3- to 5-month course of treatment. Treatment fidelity is maintained by weekly group supervision meetings involving 3 to 4 therapists and a Doctoral-Level or advanced Master's-Level clinical supervisor. The group reviews the goals and progress of each case to ensure the multisystemic focus of the therapists' intervention strategies, identify barriers to success, and facilitate the attainment of treatment goals. In addition, an MST expert consultant reviews each case with the team weekly to promote treatment fidelity and favorable clinical outcomes.

      The design and implementation of MST interventions are based on the following nine core principles of MST. An extensive description of these principles, with examples that illustrate the translation of these principles into specific intervention strategies are provided in comprehensive clinical volumes (Henggeler et al., 1998; 2009).

      1. The primary purpose of assessment is to understand the "fit" between the identified problems and their broader systemic context.
      2. Therapeutic contacts emphasize the positive and use systemic strengths as levers for change.
      3. Interventions are designed to promote responsible behavior and decrease irresponsible behavior among family members.
      4. Interventions are present-focused and action-oriented, targeting specific and well-defined problems.
      5. Interventions target sequences of behavior within and between multiple systems that maintain the identified problems.
      6. Interventions are developmentally appropriate and fit the developmental needs of the youth.
      7. Interventions are designed to require daily or weekly effort by family members.
      8. Intervention effectiveness is evaluated continuously from multiple perspectives with providers assuming accountability for overcoming barriers to successful outcomes.
      9. Interventions are designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering caregivers to address family members' needs across multiple systemic contexts.

      MST is based upon the social-ecological model of behavior. According to this perspective, behavior is determined through the reciprocal interplay of the child and his or her social ecology, including the family, peers, neighborhood, and other community settings. Research demonstrates that there are factors within the social settings youth are embedded that put youth at greater risk for criminal and antisocial behavior. Likewise, there are also factors within the social environment that encourage involvement in prosocial behavior and protect youth from involvement in antisocial and criminal behavior. Problem behavior may be a function of difficulty within any of these social settings and/or difficulties that characterize the interfaces between these settings (i.e., family-school relations or family-neighborhood relations). Based on this theoretical rationale, MST interventions are tailored to address the specific risk and protective factors that are salient to the social environments of the individual and family receiving the treatment.

      • Person - Environment

      Twenty-five evaluations of MST have been published, and 22 of these used randomized designs. The majority of these studies were conducted with serious juvenile offenders and juvenile offenders, including violent offenders, substance abusing offenders, and juvenile sex offenders. Multimethod (self-report, parent report, biological, and archival) assessment strategies have been used to examine the effects of the MST program on criminal behavior and incarceration, family relations, peer relations, psychiatric symptomatology, and drug use. Several randomized trials in the U.S. and Europe were conducted without direct oversight by the model developers. MST has also been adapted and tested for conditions other than delinquency, for instance, obesity, diabetes, child abuse and neglect, and serious emotional disturbances (these studies are written separately).

      Most of the findings from randomized studies of MST provide evidence that MST can produce short- and long-term reductions in criminal behavior and out-of-home placements for serious juvenile offenders. In the Simpsonville, South Carolina study, for example, MST youth had more than half as many arrests as youth receiving the usual services. This was maintained at the 2.4 year follow-up evaluation, which showed that MST doubled the percentage of youth not rearrested, in comparison to the usual services group. In the Columbia, Missouri study, at the four-year follow-up, a significantly lower percentage of MST youth had been arrested at least once, compared to those in individual therapy. At 21.9 years post-treatment, MST participants compared to control counterparts were less likely to be arrested, had fewer arrests and fewer days in confinement; the same was true at 25 years post-treatment evaluation of siblings of the original subjects. On the basis of archival incarceration records for youth in the multisite South Carolina study, the annualized rate of days incarcerated was 47% lower for youth in the MST condition (33.2 days per year per youth) than their usual services counterparts (70.4 days per year per youth). However, this study showed no significant treatment effects on the self-reported delinquency assessment. Likewise, there were no significant treatment effects on measures of self-reported criminal activity or arrests at posttest for youth in the Charleston County, South Carolina study. Although at the four-year follow-up MST youth in the Charleston County, South Carolina study showed a 75% reduction in convictions for aggressive crimes and reported committing fewer aggressive crimes, compared to those who received the usual services. In the midwestern state study, those in the treatment as usual group were 3.2 times more likely than youths in the MST group to be arrested. However, in that study both groups had high recidivism rates.

      The results from the Canada study do not show significant effects for MST in regards to convictions, sentencing, and length of time in custody. Members of the MST group were significantly more likely to be sentenced to a term of open custody and significantly less likely to be sentenced to a term of secure custody, compared to the usual services group. This pattern was observed in three sites. However, MST youth improved significantly on some problems as measured by psychological testing. Compared to the control group, the MST youth improved significantly on parent reports of family adaptability, caregiver depression, and youths' externalizing behavior. The MST group also improved significantly on youth report of internalizing symptoms when compared to the control group.

      MST has mixed results on drug use outcomes. For example, in the Simpsonville, South Carolina study, self-reported soft drug use was significantly lower at posttest for the youth in the MST condition than for the youth in the usual services condition. MST youth in the Columbia, Missouri study had a significantly lower rate of substance-related arrests than youth in individual therapy. However, in the Charleston County, South Carolina study, there were no significant treatment effects on self-reported drug use at post-treatment. There were significantly higher rates of marijuana abstinence at the four-year follow-up among intervention youth, compared with their usual services counterparts. In the midwestern state study, evaluations of substance abuse were not significant when comparing MST participants to those receiving treatment as usual.

      Results regarding MST program fidelity are mixed as well. For example, in the Multisite South Carolina study, high adherence to the MST protocol based on parent, adolescent, and therapist reports predicted favorable outcomes, and low adherence predicted poor outcomes on the following measures: adolescent symptomatology, rates of parental and emotional distress, adolescent self-reports of index offenses, rates of re-arrest, and rates of incarceration. However, MST treatment adherence was not related to outcome measures in the Charleston County, South Carolina study.

      Studies on MST as an intervention for juvenile sexual offenders showed very positive results. MST participants had lower recidivism rates than did youth in the control (treatment as usual) group for both sexual and nonsexual crimes. MST participants also had fewer arrests for all crimes and spent fewer days confined in detention facilities than their control group counterparts (Borduin, Schaeffer and Heiblum, 2009). A second study on juvenile sexual offenders (Letourneau et al. 2009) showed that youth in the MST condition evidenced significant reductions in sexual behavior problems, delinquency, substance use, externalizing symptoms, and out-of-home placements.

      The randomized trial of juvenile offenders conducted in the U.S. without the direct oversight by the program developers (Timmons-Mitchell, et al., 2006) demonstrated significant reduction in rearrest and improvement in four areas of functioning (home, school, community, and moods and emotions). Substance use showed a non-significant trend favoring the MST group. In a similar U.S.-based independent replication study of adolescents drawn from schools rather than the justice system (Weiss et al., 2013), 3 of 9 outcomes were improved relative to the control group: parents and adolescents reported fewer externalizing problems, and adolescents decreased absenteeism in school. Another independent replication study in Los Angeles, California (Fain et al., 2014) found that rates of re-arrest, incarceration, and completion of community service were higher in MST youth than in the comparison group, but that the findings held only for Hispanics/Latinos and not African Americans.

      The key finding from an independent replication in London (Butler, et al., 2011) was that the MST model reduced significantly more, relative to controls, the likelihood of nonviolent offending during the 12-month follow-up period. In addition, a decrease in aggression, delinquency, and psychopathic traits as well as an increase in positive parenting was observed at posttest comparing the MST to the Youth Offending Team (YOT) control group. Similarly, an independent replication in Norway showed that MST, in comparison with usual services, decreased youth externalizing and internalizing symptoms and out-of-home placements, and that some effects were sustained for at least two years (Ogden & Hagen, 2006). Independent replication in the Netherlands demonstrated MST-related reductions in Externalizing, Oppositional Defiant Disorder, Conduct Disorder, and Property Offenses.

      Changes in family relations and delinquent peer affiliation mediate the relationship between MST treatment and delinquency.

      Simpsonville, SC: Compared to youth receiving usual services, MST youth had:

      • Significantly lower delinquency on multiple measures: self-reported offenses, self-reported drug use, arrests, incarceration, and days incarcerated in DYS facilities.
      • Double the nonrecidivism rate by the 2.4 year follow-up.

      Columbia, MO: Relative to the comparison group, MST:

      • Decreased youth behavior problems reported by mothers.
      • Led to 70% fewer arrests among recidivists, typically for less serious crimes.
      • Led to fewer arrests and convictions, and fewer days in confinement at the 13.7 year and 21.9-year follow-ups.
      • The closest sibling of the target of the MST intervention had significantly fewer arrests and convictions than the control group siblings at the 25-year follow-up.

      Multisite, SC: Compared to the control group:

      • Decreased psychiatric symptomatology in youth.
      • The annualized rate of days incarcerated was 47% lower for youth in MST.

      Charleston, SC: Relative to the control group, MST showed:

      • No significant treatment effects on measures of drug use, self-reported criminal activity, and arrest records.
      • A 75% reduction in convictions for aggressive crimes and higher rates of marijuana abstinence (55% versus 28%) at the 4-year follow-up.

      Los Angeles, CA (Fain et al., 2014): Relative to a comparison group, MST youth improved:

      • Rates of re-arrest, incarceration, and completion of community service.
      • Improvements in arrests, incarceration, and completion of probation were only found among Hispanic youth, not African American youth.

      Canada Study: Compared to the control group, the MST group showed:

      • No significant differences on convictions, sentencing, and length of time in custody.
      • Significantly more open custody sentences and fewer secure custody sentences.
      • Significantly better parent reports of youths’ externalizing behavior.
      • Significantly better youth reports of internalizing symptoms.

      Juvenile Sexual Offender Studies (Three Studies): Compared to the control group, MST youth had:

      • Fewer arrests and lower recidivism rates for both sexual and nonsexual crimes.
      • Significant reductions in sexual behavior problems, delinquency, substance use, externalizing symptoms, and out-of-home placements.

      Midwestern State Study (Timmons-Mitchell, et al., 2006) - Independent Replication

      • MST recidivism rates (66.7%) were significantly lower than rates for those receiving treatment as usual (86.7%).
      • Youths in the treatment-as-usual group were 3.2 times more likely than MST youths to be rearrested.
      • MST showed improvement in functioning over time on four measures: school, home, work, and moods and emotions.

      U.S. School-based Study (Weiss et al., 2013) - Independent Replication
      Relative to the control group, MST adolescents improved:

      • Parent and adolescent reports of externalizing behaviors.
      • Absenteeism at school.

      Norwegian Study (Ogden & Halliday-Boykins, 2004; Ogden & Hagen, 2006) - Independent Replication

      • MST decreased youth externalizing and internalizing symptoms.
      • Decreased out-of-home placements.

      London Study (Butler et al. 2011) - Independent Replication: Compared to a control group, MST produced a:

      • Significant decrease in nonviolent offenses at the 12-month follow-up assessment.
      • Decrease in aggression, delinquency, and psychopathic traits at posttest.

      Netherlands Study (Dekovic et al., 2012; Asscher et al., 2013, 2014)
      Relative to the control group, MST adolescents improved:

      • Parent- and adolescent-reported Externalizing
      • Oppositional Defiant Disorder
      • Conduct Problems
      • Adolescent-reported Property Offenses

      Several studies demonstrated program effects on 1) instrumental outcomes such as family relations, peer relations, and individual adjustment and 2) ultimate outcomes such as delinquency and arrests. With instrumental outcomes viewed as mediators that translate program action into ultimate outcomes, the studies offer partial evidence of mediation.

      In addition, one study (Huey et al. 2000) used data from Studies 4 and 6 to perform a full mediation analysis. In both samples, the findings demonstrated that therapist adherence to MST significantly improved family functioning, which in turn reduced delinquent peer affiliation and delinquent behavior. However, another study (Butler et al. 2011) found that positive parenting and adherence to MST standards did not mediate the program's effect on youth outcomes.

      For a sample of Dutch families, Dekovic et al. (2012) found that improvements in parental competence due to the program subsequently improved positive discipline and reduced child externalizing behavior.

      Overall, studies offer clear evidence that MST produces benefits through the posited mechanisms.

      The few studies that presented program effects sizes (Cohen’s d) showed coefficients that varied around an average .5 – or a medium impact. Study 1 (Henggeler, Melton, & Smith, 1992) reported values of .34 for peer aggression, .45 for rearrest, .55 for self-reported delinquency, and .62 for incarceration. Study 7 (Ogden & Hagen, 2005) reported values of .26 for self-reported delinquency, .50 for parent’s ratings of behavior, and .68 for teacher’s ratings of behavior. Study 14 (Dekovic et al., 2012) found effect sizes ranging from .2 to .5. For the school-based study (Weiss et al., 2013), significant effects were small to medium (Cohen’s d), ranging from .25 to .43 for externalizing problems.

      Controlled studies have supported the effectiveness of MST in treating inner-city juvenile offenders, child abuse and neglect, adolescent sexual offenders, chronic, serious and violent juvenile offenders, and substance abusing delinquents. It is equally effective with youths of different ethnic backgrounds, gender, age, and with families possessing different levels of cohesion and varying strengths and weaknesses. Study 6 demonstrated that for females, MST was effective in decreasing alcohol and marijuana use from T1 to T2 in comparison to the US group, but between T2 and T3 female alcohol and marijuana use significantly increased for females in the MST condition, whereas counterparts in the US condition improved. In the Simpsonville and Columbia studies MST has been determined to be effective for both genders. In a Norway study which examined gender differences, MST was effective regardless of gender with similarities between girls and boys outnumbering their differences. MST has also been adapted and tested for conditions other than delinquency, for instance, obesity, diabetes, and serious emotional disturbance. These studies are written separately, but have shown success with these different populations.

      While most studies used participants drawn from the criminal legal system, one study using a sample taken from public school behavioral-modification classrooms showed similar results on externalizing behaviors.

      MST has been implemented in a variety of settings and with a variety of adolescents presenting problems such as delinquency, substance use, and sexual offending. Most studies are randomized, and most find positive results on the Blueprints outcomes of interest. Considering the vast array of studies, any limitations would have to be noted study by study. Overall, the methodology is good in the studies. The one problem is an independent Canadian replication that found MST to be ineffective.

      • Blueprints: Model Plus
      • Crime Solutions: Effective
      • OJJDP Model Programs: Effective
      • SAMHSA: 2.9-3.2

      Domestic
      Mike Williams
      MST Program Manager, Network Partner Director
      Advanced Behavioral Health
      mwilliams@abhct.com
      Phone number: (860) 704-6436

      International
      Cathy James
      MST Programme Lead MSTUK
      National Implementation Service
      cathy.james@kcl.ac.uk
      0207 848 5843

      Asscher, J. J., Deković, M., Manders, W. A., van der Laan, P. H., Prins, P. J. M., &
 the Dutch MST Cost-Effectiveness Study Group 4. (2013). A randomized controlled trial of the effectiveness of Multisystemic Therapy in the Netherlands: Post-treatment changes and moderator effects. Journal of Experimental Criminology, 9, 169-187.

      Asscher, J. J., Deković, M., Manders, W. A., van der Laan, P. H., Prins, P. J. M., van Arum, S., &
 the Dutch MST Cost-Effectiveness Study Group 4. (2014). Sustainabilityof the effects of multisystem therapy for juvenile delinquents in The Netherlands: effects on delinquency and recidivism. Journal Experimental Criminology, 10, 227-243.

      Borduin, C. M., Henggeler, S. W., Blaske, D. M., & Stain, R. J. (1990). Multisystemic treatment of adolescent sexual offenders. International Journal of Offender Therapy and Comparative Criminology, 35, 105-114.

      Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., Fucci, B. R., Blaske, D. M. & Williams, R. A. (1995). Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology, 63, 569-578.

      Borduin, C.M., Schaeffer, C.M. & Heiblum, N. (2009). A randomized clinical trial of Multisystemic Therapy with juvenile sexual offenders: Effects on youth social ecology and criminal activity. Journal of Consulting and Clinical Psychology, 77(1), 26-37.

      Brown, T. L., Henggeler, S. W., Schoenwald, S. K., Brondino, M. J., & Pickrel, S. G. (1999). Multisystemic treatment of substance abusing and dependent juvenile delinquents: Effects on school attendance at posttreatment and 6-month follow-up. Children's Services: Social Policy, Research, and Practice, 2(2), 81-93.

      Butler, S., Baruch, G., Hickey, N., & Fonagy, P. (2011). A randomized controlled trial of Multisystemic Therapy and a statutory therapeutic intervention for young offenders. Journal of the American Academy of Child and Adolescent Psychiatry, 50(12), 1220-1235.

      Camp, G. M. & Camp, C. G. (1993). The Corrections Yearbook. South Salem, N. Y.: Criminal Justice Institute.

      Dekovic, M., Asscher, J. J., Manders, W. A., Prins, P. J. M., & van der Laan, P. (2012). Within-intervention change: Mediators of intervention effects during Multisystemic Therapy. Journal of Consulting and Clinical Psychology, 80(4), 574-587.

      Fain, T., Greathouse, S. M., Turner, S. F., & Weinberg, H. D. (2014). Effectiveness of Multisystemic Therapy for minority youth: Outcomes over 8 years in Los Angeles County. Journal of Juvenile Justice, 3(2), 24-37.

      Henggeler, S. W., Borduin, C. M., Melton, G. B., Mann, B. J., Smith, L. A., Hall, J. A., Cone, L., & Fucci, B. R. (1991). Effects of multisystemic therapy on drug use and abuse in serious juvenile offenders: A progress report from two outcome studies. Family Dynamics of Addiction Quarterly, 1(3), 40-51.

      Henggeler, S. W., Clingempeel, W. G., Brondino, M. J., & Pickrel, S. G. (2002). Four-year follow-up of Multisystemic Therapy with substance-abusing and substance-dependent juvenile offenders.Journal of the American Academy of Child and Adolescent Psychiatry, 41(7), 868-874.

      Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G., & Hanley, J. H. (1997). Multisystemic Therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology, 65, 821-833.

      Henggeler, S. W., Melton, G. B., & Smith, L. A. (1992). Family preservation using multisystemic therapy: An effective alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical Psychology, 6, 953-961.

      Henggeler, S. W., Melton, G. B., Smith, L. A., Schoenwald, S. K., & Hanley, J. H. (1993). Family preservation using multisystemic treatment: Long-term followup to a clinical trial with serious juvenile offenders. Journal of Child and Family Studies, 2, 283-293.

      Henggeler, S. W., Pickrel, S. G., & Brondino, M. J. (1999). Multisystemic treatment of substance-abusing and dependent delinquents: Outcomes, treatment fidelity, and transportability. Mental Health Services Research, 1(3), 171-184.

      Henggeler, S. W., Rodick, J. D., Borduin, C. M., Hanson, C. L., Watson, S. M., & Urey, J. R. (1986). Multisystemic treatment of juvenile offenders: Effects on adolescent behavior and family interaction. Developmental Psychology, 22, 132-141.

      Henggeler, S. W., Schoenwald, S .K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (1998). Multisystemic Treatment of Antisocial Behavior in Children and Adolescents. New York: Guilford.

      Henggeler, S. W., Schoenwald, S .K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (2009). Multisystemic therapy for antisocial behavior in children and adolescents (2nd ed.)., New York: Guilford Press.

      Huey, S.J., Henggeler, S.W., Brondino, M.J., & Pickrel, S.G. (2000). Mechanisms of change in multisystemic therapy: Reducing delinquent behavior through therapist adherence and improved family and peer functioning. Journal of Consulting and Clinical Psychology, 68(3), 451-467.

      Leschied, A. & Cunningham, A. (2002). Seeking Effective Interventions for Serious Young Offenders: Interim Results of a Four-Year Randomized Study of Multisystemic Therapy in Ontario, Canada. London, Canada: Centre for Children and Families in the Justice System.

      Letourneau, E.J., Henggeler, S.W., Borduin, C.M., Schewe, P.A., McCart, M.R., Chapman, J.E., & Saldana, L. (2009). Multisystemic Therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. Journal of Family Psychology, 23(1), 89-102.

      Manders, W. A., Dekovie, J., Asscher, J. J., van der Laan, P. H. & Prins, P. J. M. (2013). Psychopathy as predictor and moderator of Multisystemic Therapy outcomes among adolescents treated for antisocial behavior. Journal of Abnormal Child Psychology, 41, 1121-1132.

      Ogden, T. & Halliday-Boykins, C. A. (2004). Multisystemic treatment of antisocial adolescents in Norway: Replication of clinical outcomes outside of the US. Child and Adolelscent Mental Health, 9(2), 77-83.

      Ogden, T. & Hagen, K.A. (2009). What works for whom? Gender differences in intake characteristics and treatment outcomes following Multisystemic Therapy. Journal of Adolescence, 32, 1425-1435.

      Ogden, T. & Hagen, K.A. (2006). Multisystemic Therapy of serious behaviour problems in youth: Sustainability of therapy effectiveness two years after intake. Journal of Child and Adolescent Mental Health, 11, 142-149.

      Sawyer, A.M, & Borduin, C.M. (2011). Effects of Multisystemic Therapy through midlife: A 21.9-year follow-up to a randomized clinical trial with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology, 79(5), 643-652.

      Schaeffer, C. M. & Borduin, C. M. (2005). Long-term follow-up to a randomized clinical trial of Multisystemic Therapy with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology, 73(3), 445-453.

      Schoenwald, S. K., Ward, D. M., Henggeler, S. W., Pickrel, S. G., & Patel, H. (1996). Multisystemic Therapy treatment of substance abusing or dependent adolescent offenders: Costs of reducing incarceration, inpatient, and residential placement. Journal of Child and Family Studies, 5(4), 431-444.

      Timmons-Mitchell, J., Bender, M., Kishna, M.A., & Mitchell, C. (2006). An independent effectiveness trial of Multisystemic Therapy with juvenile justice youth. Journal of Clinical Child and Adolescent Psychology, 35(2), 227-236.

      Wagner, D. V., Borduin, C. M., Sawyer, A. M., & Dopp, A. R. (2014). Long-Term Prevention of Criminality in Siblings of Serious and Violent Juvenile Offenders: A 25-Year Follow-Up to a Randomized Clinical Trial of Multisystemic Therapy. Journal of Consulting and Clinical Psychology, 82(3), 492-499.

      Weiss, B., Han, S., Harris, V., Catron, T., Ngo, V. K., Caron, A., Gallop, R., & Guth, C. (2013). An independent randomized clinical trial of Multisystemic Therapy with non-court-referred adolescents with serious conduct problems. Journal of Consulting and Clinical Psychology, 81(6), 1027-1039.

      Marshall Swenson, MSW, MBA
      MST Services, Inc.
      710 J. Dodds Boulevard, Suite 200
      Mount Pleasant, SC 29464
      Phone: (843) 856-8226
      marshall.swenson@mstservices.com
      www.mstservices.com or www.mstinstitute.org

      Study 3

      Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., Fucci, B. R., Blaske, D. M. & Williams, R. A. (1995). Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology, 63, 569-578.

      Sawyer, A.M, & Borduin, C.M. (2011). Effects of Multisystemic Therapy through midlife: A 21.9-year follow-up to a randomized clinical trial with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology, 79(5), 643–652.

      Schaeffer, C. M. & Borduin, C. M. (2005). Long-term follow-up to a randomized clinical trial of Multisystemic Therapy with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology, 73(3), 445-453.

      Study 7

      Ogden, T. & Halliday-Boykins, C. A. (2004). Multisystemic treatment of antisocial adolescents in Norway: Replication of clinical outcomes outside of the US. Child and Adolelscent Mental Health, 9(2), 77-83.

      Simpsonville, South Carolina (Henggeler et al., 1992)

      Evaluation Methodology

      Design: A pretest-posttest control group design, with random assignment to conditions and follow-up for arrest and incarceration measures was used to compare the effectiveness of family preservation using MST versus the usual services delivered by the Department of Youth Services (DYS). Eligible youths were referred by the DYS in yoked pairs, with one youth randomly selected to receive MST (n=43) and the other to receive the usual services (n=41). Assessments were administered to both groups at approximately the same time.

      Therapists with caseloads of 4 delivered the MST program to the treatment group. On average, the treatment duration was 13.4 weeks encompassing 33 hours of direct contact, with 24-hour-a-day case coverage. Depending on the stage of treatment, sessions were held as often as every day or as infrequently as once a week usually in the family's home and ranged in duration from 15 to 90 minutes.

      Youths in the usual service condition met monthly with a probation officer who monitored their compliance with court ordered stipulations (e.g., curfew, school attendance, participation with other agencies). Although youths and families were often referred for mental health services, few substantive services were actually delivered.

      Pretreatment and posttreatment assessments were completed by 77% of the families in the MST condition (n=33) and 56% of families in the control condition. Criminal histories and demographics of the participants completing both assessments are essentially the same as the larger sample. Tests of attrition showed families who completed both assessments, compared to those who did not, were more likely to be African-American, to have participated in the MST condition, and to have reported higher maternal symptomatology, more structured family relations, and greater social competence in the youth. Attrition analyses on premature treatment terminators were not appropriate for this study because it was not possible to terminate usual services.

      Sample: Out of 96 youths who were originally referred by DYS staff because they were at-risk for out-of-home placement due to involvement in serious criminal activity, 84 participated in the study (n=43 in MST and n=41 usual-services). Over half of the youths in the sample had been convicted of a serious violent offense and the sample averaged 3.5 previous arrests. The mean age of the sample was 15.2 years, 77% were male, 56% African American, 42% were Caucasian, and 2% were Hispanic American. The MST and usual services groups did not differ significantly on demographic variables or criminal history.

      Measures: A multimethod, multifocus measurement battery was used to assess variables related to the ultimate and instrumental goals. Ultimate outcomes included decreases in criminal activity and incarceration. Instrumental goals included improved family relations, peer relations, and social competence and decreased symptomatology in youths and parents.

      Archival records from the time of referral to the MST or control condition were evaluated for postreferral arrests and postreferral incarceration. In addition, the full-scale score of the Self-Report Delinquency scale (SRD) assessed youths' reports of criminal behavior during the previous 4 months. The Family Adaptability and Cohesion Evaluation scales (FACES) were used to assess parental and youth perceptions of family cohesion and adaptability. The Missouri Peer Relations Inventory (MPRI) evaluated parental and youth perceptions of the adolescent's friendships on the dimensions of emotional bonding, aggression, and social maturity. Adolescent symptomatology was assessed through maternal reports on the Revised Behavior Problem Checklist (RBPC). Parental symptomatology was assessed with the self-report Symptom Checklist-90-Revised (SCL-90-R) and adolescent social competence was assessed with the Social Competence scale of the Child Behavior Checklist (SCS-CBC).

      Analysis: One-way analyses of variance (ANOVA) were used to evaluate between-groups differences for arrests and incarceration following referral to the project (n=84), and one way analyses of covariance were used to evaluate between groups differences on the SRD and the psychosocial measures at the posttreatment assessment, with the corresponding pretreatment score serving as the covariate (n=56).

      Outcomes

      Posttest: Shortly after treatment ended, self-reported offenses were lower for MST youth compared to youth receiving usual services (Mean=2.9 vs. 8.6). At 59 weeks postreferral, MST youths had more than half as many arrests (Mean=0.87 vs. 1.52) as youths receiving usual services (58% of MST youths experienced no rearrests vs. 38% of usual services group). MST youths also spent an average of 73 fewer days incarcerated in DYS facilities (Mean=5.8 vs. 16.2) than usual services youth (20% of MST youths vs. 68% of usual services youth experienced incarceration). Aggression with peers decreased significantly for MST youth, while remaining the same for youth receiving usual services. Families receiving MST also reported more cohesion, whereas family cohesion decreased in the usual services condition.

      Long-term: A 2.4 year follow-up (Henggeler, Melton, Smith, Schoenwald, and Hanley, 1993) showed that MST doubled the percentage of youth not rearrested, in comparison with the usual services group.

      Simpsonville, South Carolina - Drug Study (Henggeler, Borduin, Melton, Mann, Smith, Hall, Cone, and Fucci, 1991)

      Evaluation Methodology

      Design
      : A pretest-posttest control group design, with random assignment to conditions and follow-up for arrest and incarceration measures was used to compare the effectiveness of family preservation using MST versus the usual services (US) delivered by the Department of Youth Services (DYS). At the time of this study, assessment data had been obtained for 47 youths, 28 in the MST condition and 19 in the US condition. In the MST condition, 89% of the referred families participated in treatment.

      Therapists with caseloads of 4 delivered the MST program to the treatment group. On average, the treatment duration was 13.4 weeks encompassing 33 hours of direct contact, with 24-hour-a-day case coverage. Depending on the stage of treatment, sessions were held as often as every day or as infrequently as once a week, usually in the family's home, and ranged in duration from 15 to 90 minutes.

      Youths in the usual service condition met monthly with a probation officer who monitored their compliance with court ordered stipulations (i.e., curfew, school attendance, participation with other agencies). Although youths and families were often referred for mental health services, few substantive services were actually delivered.

      Sample: The mean age of the sample was 15.1 years, 72% were male, 74% African American, and 26% were Caucasian. The MST and usual services groups did not differ significantly on demographic variables or criminal history.

      Measures: Self-reported substance abuse was measured with the soft drug use and hard drug use subscales of the self-report delinquency scale in the National Youth Survey.

      Analysis: One-way analyses of variance (ANOVA) were used to evaluate between-groups differences for self-reported drug use.

      Outcomes

      Post-test: Self-reported soft drug use was significantly lower at posttreatment for the youths in the MST condition than for the youths in the Usual Services condition. Differences between samples for hard drug use could not be tested due to a very low base rate (i.e., only three youths reported such use).

      Outcomes - Brief Bullets

      • Self-reported soft drug use was significantly lower at posttreatment for the youths in the MST condition than for the youths in the Usual Services condition.

      Limitations: Since the main focus of this project was delinquency rather than substance abuse, the measurement methods for assessing substance abuse were somewhat restricted. Because the youth in the sample were not screened for substance abuse disorders, the sample included both substance abusers and non-abusers. Treatment effects would likely be stronger if the analyses were limited to substance-abusing offenders. In addition, the sample of youth included in these analyses is only a portion of the youth included in the full study. However, this article does not include information about sample attrition.

      This study took two forms: the main analysis of the original subjects (described first) and a secondary analysis of siblings of the subjects (described second).

      Columbia, Missouri: (Borduin, Mann, Cone, Henggeler, Fucci, Blaske, and Williams, 1995; Sawyer and Borduin, 2011; Schaeffer and Borduin, 2005)

      Evaluation Methodology:

      Design
      : A prettest-posttest control group design, with random assignment to conditions and multiple follow-ups for arrests, was used to compare the effectiveness of MST with that of individual therapy (IT). Participants were 200 twelve- to seventeen- year old juvenile offenders and their families who were referred to the project by juvenile court personnel and agreed to participate in a pretreatment assessment session; five other families were referred but did not agree to participate. Twenty-four (12%) of the families refused service. The remaining 176 families were randomly assigned to receive either MST (n=92) or IT (n=84). Of these, 140 (79.5%) completed treatment, and 36 (21.5%) dropped out. Dropout rates were not significantly different for the treatment or control group. Statistical tests showed no between-group differences in the criminal histories or demographic characteristics for the IT dropouts or the MST treatment refusers. Pre and posttreatment assessments were available for 126 families. The average treatment for MST involved 23.9 hours and 28.6 hours for the IT completers. These means were significantly different.

      Sample: Juvenile offenders and their families with (a) at least two arrests (b) currently living with at least one parent figure, and (c) showed no evidence of psychosis were included in the study. The juvenile offenders were involved in extensive criminal activity as evidenced by their average 4.2 previous arrests and the fact that 63% had been incarcerated. Their average age was 14.8 years; 67% were male; 70% White, and 30% African American; 65% were from families characterized by low socioeconomic class; and 53% lived with two parental figures.

      Measures: Individual adjustment included measures of psychiatric symptomatology in mothers, fathers, and adolescents and a measure of adolescent behavior problems assessed through mothers' reports. Family relations were measured by parental and adolescent perceptions of family functioning and video-recorded observed family interactions. Maternal and teacher perceptions of peer relations were evaluated with the 13-item Missouri Peer Relations Inventory (MPRI). Juvenile court, local police, and state police records, collected an average of 3.95 years, were used to obtain data on post-probation arrests. Substance abuse was measured as an arrest for a substance-related offense.

      Analysis: Repeated measures multivariate analyses of variance (MANOVAs) and ANOVAs were used to evaluate whether significant changes pre- to post assessment were experienced by the 70 MST youths and families or the 56 IT youths and families who completed pretreatment and posttreatment assessments. Survival analysis was employed to determine the proportion of participants not arrested in each group by the length of time from release from probation. Additional analyses examined the number of arrests and the seriousness of those arrests among recidivists in the MST and IT groups. Hierarchical multiple regression analysis was used to evaluate the effect of treatment on violent offending and to evaluate the effects of potential moderators (age, race, social class, gender, pretreatment arrests) of MST effectiveness.

      Outcomes:

      Post-test: At posttest (within one week of treatment completion), MST resulted in decreased symptomatology in parents (self-reports), compared to an increase in the IT families (mothers) and no change (fathers); and decreased behavior problems in MST youth (parent reports), whereas mothers of IT youth reported an increase in behavior problems. MST families experienced favorable effects on perceived family relations (increased cohesion and adaptability) whereas cohesion and adaptability decreased in the IT condition. Observed family interactions among the MST families improved (increased supportiveness and decreased conflict-hostility across family dyads), compared to IT families in which dyadic relations deteriorated (mother-adolescent supportiveness), conflict-hostility increased (father-adolescent), or no change indicated (on measures of supportiveness and conflict-hostility).

      4 Year Follow-up: By the end of 4 years, 26.1% of youth in the MST group had been arrested at least once, compared to 71.4% of the IT group. Specifically, MST completers had lower recidivism rates (n=77, 22.1%) than MST dropouts (n=15, 46.6%), IT completers (n=63, 71.4%), IT dropouts (n=21, 71.4%), and treatment refusers (n=24, 87.5%). Additionally, recidivists in the MST group had been arrested less often and for less serious crimes than IT youth. MST youth were less likely to be arrested for violent crimes (e.g., rape, attempted rape, sexual assault, aggravated assault, assault/battery) following treatment than IT youth. MST youth also had a significantly lower rate of substance-related arrests than IT youth (4% vs. 16%) (Henggeler et al., 1991). MST was shown to be equally effective with youths of different gender and ethnic backgrounds.

      13.7 Years Post Treatment (Schaeffer and Borduin, 2005): This long-term follow-up sample consists of 87 MST and 78 IT (usual treatment) individuals. Participants were on average 28.8 years old. Both juvenile and adult substantiated (i.e., charges that were dismissed at trial were excluded) criminal records were obtained. Survival analysis to time of first arrest for various types of offenses was conducted. MST participants were at lower risk of rearrest (i.e., more likely to survive) during follow-up than were IT participants. By the end of 13.7 years, 81% of the IT group had been arrested at least once, compared with 50% of the MST group. With regard to specific offenses, MST participants were at lower risk of arrest for violent offenses, nonviolent offenses, and drug offenses during follow-up than IT participants. Additionally, MST participants had 54% fewer arrests, were sentenced to 61% fewer days of confinement in adult detention facilities and 37% fewer days of probation as adults than were comparison counterparts.

      21.9-Year Follow-Up (Sawyer and Borduin, 2011): This study began with the same 176 subjects examined in earlier studies and, like the other follow-ups, it gathered data on arrests from Missouri official records. After 21.9 years from the end of the MST program, subjects had reached an average age of 37.3 years. A search of juvenile and adult criminal arrest records in the state identified arrests that occurred after the program and that led to conviction. Those without recorded arrests and with a Missouri driver’s license were counted as having lived in the state without an arrest and conviction. Note that the records search was done for subjects who completed the program as well as for subjects who had dropped out.

      The records search determined that 84.1% of the sample (n = 148) had lived in the state since the prior follow-up. The remaining 15.9% of the sample for whom residency could not be verified were considered lost to follow-up. Attrition rates did not differ significantly across the treatment and control groups, and there were no differences in the pretreatment criminal histories or demographic characteristics of participants included in the follow-up versus participants considered lost to follow-up. The authors concluded that the loss of subjects leaving the state and unavailable for follow-up did not bias the findings.

      Outcome measures included arrests with convictions for felonies, violent felonies, nonviolent felonies, and misdemeanors (excluding traffic). The outcome measures also included civil suits involving family instability or financial problems. Since the study sampled subjects after an arrest, the new arrests indicated recidivism.

      The results revealed clear long-term benefits of MST. The treatment group had significantly better outcomes for four of the six measures: felonies, violent felonies, nonviolent felonies, and civil suits involving family instability. For example, 54.8% of control participants versus 34.8% of MST participants had been rearrested at least once for a felony offense by the end of the 21.9-year follow-up period. The odds ratio of 2.27 for control subjects relative to intervention participants indicates a medium-sized effect. The largest group difference occurred for violent felonies: The odds ratio of 4.08 for arrest for a violent felony translates into a large effect.

      Survival analyses, which model the time to arrest or censoring rather than just the occurrence of an arrest, confirmed the descriptive results. The hazard ratio for all felonies of .616 suggests a weak to medium effect of the program. Further, zero-inflated Poisson regression models examined program effects on the number of rearrests and length of sentences. The results proved less strong for these measures: The program significantly reduced only the number of arrests for misdemeanors. Tests for moderation by background factors (age, socioeconomic status, pretreatment arrests) in the zero-inflated Poisson regression showed that the results proved similar across subjects from divergent backgrounds.

      Outcomes - Brief Bullets

      • MST resulted in decreased psychiatric symptomatology in parents, compared to an increase in the comparison families.
      • Parents reported decreased behavior problems in MST youth, whereas parents of comparison group youth reported an increase in behavior problems.
      • MST families experienced favorable effects on perceived family relations, whereas cohesion and adaptability decreased in the comparison condition.
      • Observed family interactions among the MST families improved (increased supportiveness and decreased conflict-hostility across family dyads), compared to comparison families.
      • By the end of 4 years, 26.1% of the MST treatment group had been arrested at least once, compared with 71.4% of the IT group.
      • Recidivists in the MST group had been arrested less often and for less serious crimes than youth in the comparison group.
      • MST youth also had a significantly lower rate of substance-related arrests than IT youth (4% vs. 16%).
      • 13.7 years after treatment termination, MST participants were less likely than control counterparts to be arrested (50% vs. 81%), had 54% fewer arrests, and 57% fewer days in confinement. Similar results emerged after 21.9 years from treatment termination.

      Generalizability: This study shows MST to be effective with chronic, serious, and violent juvenile offenders. It was shown to be equally effective with youths of different age, gender and ethnic backgrounds. Even pretreatment arrest and number of pretreatment arrests did not moderate the effects of MST.

      Columbia, Missouri, 25 Year Sibling Follow-Up (Wagner et al., 2014):

      To examine general effects of MST beyond the youth participants, the 25-year follow-up measured arrest rates and incarceration times for the closest sibling of those targeted in the original MST study.

      Evaluation Methodology

      Design: Of the 176 randomized juveniles included in the original study, 129 had siblings in the home during the period of intervention. These 129 closest-in-age siblings, rather than the original sample, served as subjects in the 25-year follow-up.

      Assignment: The original subjects, but not the sibling subjects, were randomized to the treatment and control groups. Among the 129 siblings participating, 67 participants (51.9%) belonged to the treatment group and 62 participants (48.1%) to the control group.

      Attrition: The study obtained publicly available Missouri court records of the closest sibling to the original participants in the study. Of the 129 available participants, 19 (14.73%) appeared to have left the state, lacked data on court records, and were designated as lost to follow-up.

      Sample: Of the selected participants, 60% were the younger sibling of the MST participant, while 40% were older siblings. Half of the siblings included in the study are male. The majority of participants are white (86.4%).

      Measures: The study used publicly available adult (age 17+) criminal records. Researchers coded crime classification (felony or misdemeanor) and date of arrest. In addition, the study used the number of days sentenced to incarceration or probation. The inability to obtain data for states other than Missouri might limit the measures, as might the inability to obtain data on juvenile offenses.

      Analysis: Based on the publicly available criminal records, the study analyzed the relative odds of arrest of control and treatment group participants. In addition, the study reported the cumulative survival function for arrests. Finally, the number of arrests and years sentenced were analyzed using a Zero Inflated Poisson Regression, which evaluates the impact of treatment condition on the number of posttreatment arrests and years sentenced to incarceration or probation.

      Intent-to-Treat: The analysis excluded the 19 individuals who were lost to follow-up because of residence outside the state but otherwise used all available data.

      Outcomes:

      Baseline Equivalence: A comparison of the treatment and control siblings for the analytic sample of 110 subjects showed no significant differences on demographic variables, but the study lacked baseline measures for other variables.

      Differential Attrition: No baseline differences on condition or demographic variables were reported between those located and those lost to follow-up, but the study lacked baseline measures for other variables.

      Long-Term:

      • Siblings in the control group were significantly more likely to have been arrested at least once as compared to siblings in the treatment group (OR = 3.36).
      • A log-rank test of the survival functions for the treatment and control group showed that the treatment group was at a significantly lower risk of arrest (p=.004) and misdemeanor arrest (p=.02) during the follow-up period than the control group.
      • The Zero Inflated Poisson Regression analysis included the odds estimate for any arrests and rate estimates for number of arrests. The treatment significantly reduced odds estimate of arrest for any crime, any felony, and any misdemeanor but did not influence the number of arrests.
      • The Zero Inflated Poisson Regression also examined adult sentencing, finding that the treatment significantly reduced the odds of incarceration and probation and the years of the sentence for incarceration and probation.

      Multisite South Carolina: (Henggeler, Melton, Brondino, Scherer, and Hanley, 1997)

      Evaluation Methodology:

      Design: This study followed a 2 x 2 x 2 Condition (MST vs. usual services [US] x Time (pretest vs. posttest) x Site (Site 1 [S1] vs Site 2 [S2]) mixed factorial design, with random assignment. Eighty-two families were randomly assigned to MST treatment conditions and 73 to usual services. Families from each group were paired to further control for historical and related threats to validity. Nine of the families could not be paired. Between pretest and posttest, 9.7% (n=15) of the families dropped out of the study. Mothers from the dropout group were slightly better educated than mothers from the completers. Two sites, covering a three county area, were chosen to achieve representation of racial group and urban and rural settings. S1 encompassed urban and rural areas and had a majority Caucasian population, while S2 was mostly rural and majority African American.

      The average treatment for the MST groups involved 122.6 days for S1 and 116.6 for S2. Youths in the US condition were placed on probation for a minimum of 6 months and typically seen by his or her probation officer at least once per month. School attendance was monitored and referrals were made to other social service agencies for help in particular problem areas (e.g., alcohol and drug abuse programming, vocational counseling or training).

      Sample: To be included in the study, adolescents had to (a) be between 11 and 17 years (b) have committed a serious criminal offense or have at least three prior criminal offenses other than status offenses, and (c) be at imminent risk of being placed outside the home because of serious criminal involvement. The juvenile offenders averaged 3.07 previous arrests and 59% had been incarcerated at least once. At the time of referral their average age was 15.22 years; 81.9% were male; 19.4% were White, and 80.6% were African American; approximately 50% were from two parent households and the median family income was between $5,000 and $10,000 per year.

      Measures: Individual emotional adjustment and adolescent behavior problems, criminal activity, family relations, parental monitoring, peer relations, and MST treatment adherence were all measured in this study. Primary caregiver and adolescent psychological distress were assessed by the Global Severity Index. Adolescent behavior was measured through caregiver reports. A self-report delinquency scale was utilized to assess criminal activity during the previous 3 months. Arrest and incarceration histories were collected approximately 1.7 years from the end of the project and included offense, arrest, adjudication, and incarceration histories. Assessments of family functioning, parental monitoring, and peer relations were provided by reports from the primary caregiver and the adolescent. The MST Adherence Measure was completed by the parents, adolescents, and therapists after randomly selected therapy sessions.

      Analysis: A series of 2 x 2 x 2 Time (pretreatment vs. posttreatment) x Treatment Condition (MST vs. US) x Site (S1 vs. S2) ANOVAs were conducted on the psychosocial measures collected during the pretreatment and posttreatment assessments. In addition, 2 x 2 (Treatment Condition x Site) ANOVAs were used to evaluate longer term outcomes for rearrest and incarceration through the 1.7 year follow-up. Hierarchical multiple regression analyses were conducted to test whether outcomes in the MST condition were associated with treatment adherence.

      Outcomes:

      Youths in the MST condition reported substantially reduced psychiatric sympotomatology, whereas their US counterparts reported slightly increased symptomatology. There were no significant treatment effects for youth reports on the self-reported delinquency assessment. The annualized rate of rearrest and the average seriousness of rearrests did not differ significantly between groups. On the basis of archival incarceration records, the annualized rate of days incarcerated was 47% lower for youths in the MST condition (33.2 days per year per youth) than their US counterparts (70.4 days per year per youth). No treatment effects were observed on the family relations measures or for the peer relations measure.

      Results in this study show that MST program fidelity is significantly associated with many of the outcome measures. High adherence based on parent, adolescent, and therapist reports predicted favorable outcomes, and low adherence predicted poor outcomes on the following measures: adolescent symptomatology, rates of parental and emotional distress, adolescent self-reports of index offenses, rates of rearrest, and rates of incarceration.

      Outcomes - Brief Bullets

      • Youths in the MST condition reported substantially reduced psychiatric symptomatology, compared to the US group.
      • The annualized rate of days incarcerated was 47% lower for youths in the MST condition, compared to the control group.
      • Therapist adherence to the MST treatment protocol was significantly associated with decreased rates of rearrest and incarceration during the 1.7 year follow-up.

      Generalizability: This study shows MST to be effective with chronic, serious, and violent juvenile offenders.

      Mediation: (Huey, et al., 2000): Across two independent samples, the study above and the Charleston County, SC, Drug Study (Study 6 in this writeup), results supported a family-centered mediation model. The model results demonstrated tthat MST improved family relations (i.e., quality of family functioning, family cohesion, and parent monitoring), and improved family relations in turn predicted decreased delinquent peer affiliation and subsequent delinquent behavior.

      Memphis, Tennessee - First published study of MST (Henggeler, Rodick, Borduin, Hanson, Watson, and Urey, 1986).

      Evaluation Methodology

      Design: A 3 X 2 mixed factorial design was used with three groups of adolescents and their families (family-ecological treatment, alternative treatment families, and normal controls). Offenders were not randomly assigned to treatment groups, but the groups were matched on demographic variables and pretreatment arrest histories. One hundred sixteen families of juvenile offenders were referred to the family-ecological treatment between June 1978 and June 1982. Alternative treatment families were the delinquent control group and consisted of 40 juvenile offenders and their families, who were referred to other mental health agencies for services. To control for developmental maturation and to provide a frame of reference, 50 nonpathological adolescents and their families who matched the demographic characteristics of the treatment families were recruited from local high schools for participation in the study. Pre- and post-treatment (3 weeks after treatment terminated) data was gathered for 57 treatment families, 23 alternate treatment families, and for 44 control families. The style and quantity of the family-ecological treatment was based on the family's needs and varied widely (from 2 to 47 hours, M=20 hours). Alternative treatment hours averaged 24 hours of intervention over an approximately 3-month period.

      Sample: Specific characteristics of the sample, beyond the information listed above, were not provided in this study.

      Measures: Child psychopathology was measured through youths self-reports, family member's self-reports of their perceptions of family relations, and observational measures of family relations based on the audio-recording of members' discussions.

      Analysis: To determine an appraisal of any differential changes experienced by the three groups during the treatment period, a test of significance was used to show whether there was a significant multivariate effect for the set of dependent measures. If a significant effect was found, a 3 x 2 mixed factorial ANOVA was performed on each measure in the set. If the ANOVA revealed a significant interaction effect, the Scheffe test was used to evaluate the pre-post changes for each group on that measure.

      Outcomes

      Results showed that adolescents in the family-ecological condition had a decrease in behavior problems on each of the subscales: conduct problem, anxiety-withdrawal, immaturity, and socialized aggression. Alternative treatment and normal control adolescents showed no change. No significant multivariate interaction effects emerged in self-reported family relations. However, observational ratings indicated significant positive change among the family-ecological group (e.g., the mother-adolescent and marital dyads were warmer and more affectionate, and the adolescent was more actively involved in family discussions after treatment). Such changes were not observed for the alternate treatment group, and some family relations had deteriorated in this group (the marital relationship and the father-adolescent relationship in these families showed decreased warmth and affection following treatment).

      Outcomes - Brief Bullets

      • Adolescents in the treatment condition showed a decrease in behavior problems, while the comparison groups showed no change.
      • Observational ratings indicated significant positive change among the family-ecological group on the family relations measure.

      Generalizability: This study supports the efficacy of the family-ecological approach with inner-city adolescent juvenile offenders. There was no discussion of the racial and gender characteristics of the sample.

      Limitations: Subjects were not randomly assigned to the treatment and control groups. Also, the therapists of the alternative treatment adolescents were considerably more experienced than the family-ecological therapists. Because this confound favored the alternative treatment group, the probability of erroneously concluding that the family-ecological treatment was superior to the alternative treatment was less likely to be inflated.

      Charleston County, South Carolina - Drug Outcomes (Henggeler, Pickrel, and Brondino, 1999; Brown, Henggeler, Schoenwald, Brondino, and Pickrel, 1999)

      Evaluation Methodology


      Design: The study followed a 2 (treatment type: MST vs. usual services) x 3 (time: pretreatment [T1], posttreatment [T2], and 6-month follow-up [T3]) mixed factorial design, with random assignment of participating families to the treatment condition (N=58) and usual services control condition (N=60). Out of 140 screened adolescents, 84% (N=118) agreed to participate in the study. Fifty-seven out of the 58 (98%) of the families assigned to the MST condition completed a full course of treatment, while 47 (78%) of the families assigned to the usual services condition completed treatment.

      The amount of MST therapeutic services each family received was based on clinical need. Families in the MST condition received services for an average of 130 days, with an average of 40 hours direct contact. Youths in the comparison condition were referred by their probation officer to receive outpatient substance abuse services from the local office of the state substance abuse commission. Youths in this condition received few substance abuse or mental health services during the first 5 months following recruitment into the project. In fact, 78% of these families received no treatment.

      An examination of the baseline comparability between youths and families in the treatment and control groups revealed youths in the MST condition reported higher rates of drug use prior to treatment.

      Sample: Participants were 118 twelve to seventeen year-old adolescents recruited from the Department of Juvenile Justice in Charleston County, South Carolina. To be included in the study, youth met diagnostic criteria for substance abuse or dependence, had formal or informal probationary status, and lived with at least one parent figure. The average age of the sample was 15.7 years at the time of referral with 79% male, 50% African American, 47% Caucasian, 1% Asian, 1% Hispanic American, and 1% Native American. Based on socioeconomic measures, the sample is relatively disadvantaged.

      Measures: A multimethod (self-report, parent report, biological, and archival) strategy was used to examine the following three outcomes: drug use, criminal activity, and out-of-home placement. Adolescent drug use was assessed through adolescent self-reports and urine toxicology screenings. Adolescent criminal activity was measured through youth self-reports on the Self-Report Delinquency Scale (SRD) and computerized arrest records. Days in out-of-home placements were documented through the monthly service utilization survey. MST program adherence was assessed using the 26-item MST Adherence Measure, which was administered to the primary caregivers and youths in the MST condition and completed by the project's three therapists following randomly selected therapy sessions. Three measures were used to obtain school attendance data: a school data form (SDF), the Child Behavior Checklist, and the monthly service utilization survey completed by the MST therapist (Brown, Henggeler, Schoenwald, Brondino, and Pickrel, 1999).

      Analysis: To determine the effects of self-report drug use and delinquency, comparisons were conducted contrasting the behavior between the MST and usual services groups over the three time intervals. Analyses were conducted within the context of 2 (treatment condition) x 3 (time: T1, T2, and T3) mixed model analyses of variance (ANOVA), with one between- and one within-subjects factor. Due to the between group differences between reported drug use at baseline, analyses of covariance were also conducted on the drug use measures. One-way ANOVAs were conducted to measure arrests, out-of-home placements, and the rates of positive drug testing during treatment. Regression analyses were conducted to test whether adherence scores were associated with key outcomes. A 2 (condition: MST vs. US) x 3 (Time: pretreatment, posttreatment, 6-month follow-up) repeated measures ANOVA was conducted to examine changes in school participation across the treatment conditions over time.

      Outcomes

      Post-test: There were no significant treatment effects on the drug use measures (using ANCOVA), self-reported criminal activity, or arrest records. Although more youth in the MST group were incarcerated (19), compared with 16 youth in the US group, the MST youths were incarcerated for substantially shorter durations (569 days vs. 1051 days). MST fidelity outcomes showed modest results: decreased drug use at T2 but not at T3; a 50% decrease in days in out-of-home placement; and no effects for self-reported offending or the urine screens.

      Comparisons of MST adherence across three studies, showed the current study on adolescent drug abuse were the worst (e.g., lowest adherence and highest non-productive sessions). Overall, adherence scores were marginally associated, in the expected direction, with criminal activity and out-of-home placement. The findings are contradictory in the observed associations between treatment adherence and adolescent drug use. Some results demonstrate higher fidelity is related to improved youth outcomes (e.g., adolescent reports of high treatment adherence were associated with reduced probability of using drugs other than alcohol and marijuana at T3). On the other hand, several findings showed the opposite effects (e.g., caregiver ratings of high adherence were associated with increased adolescent alcohol and marijuana use at T2).

      MST effects were moderated in two instances. For females, MST was effective in decreasing alcohol and marijuana use from T1 to T2 in comparison to the US group, but between T2 and T3 female alcohol and marijuana use significantly increased for females in the MST condition, whereas counterparts in the US condition improved. A similar finding was revealed for age. For younger adolescents (age 15 and below), MST was effective in decreasing alcohol and marijuana use from T1 to T2 in comparison to the US group who increased, but between T2 and T3 younger adolescents in the MST group significantly increased their alcohol and marijuana use, whereas counterparts in the US condition decreased their use.

      Participants in the MST condition showed a sustained increase in the percentage of adolescents in school through the 6-month follow-up. In contrast, the percentage of adolescents in school in the US condition decreased at posttreatment but then increased at the 6-month follow-up (Brown, Henggeler, Schoenwald, Brondino, and Pickrel, 1999).

      Outcomes - Brief Bullets

      • There were no significant treatment effects on the biological drug use measures, measures of self-reported criminal activity, or arrest records.
      • MST outcomes showed decreased drug use at the second assessment and a 50% decrease in days in out-of-home placement.
      • Comparisons of MST adherence across three studies, showed the current study on adolescent drug abuse had the lowest adherence.
      • Participants in the MST condition showed a sustained increase in the percentage of adolescents in school through the 6-month follow-up.

      Generalizability: The sample is a relatively diverse population of adolescents who met the diagnostic criteria for substance abuse or dependence and had formal or informal probationary status. This study showed mixed results regarding the effectiveness of MST with this population.

      Notes: Previous studies support the potential viability of MST for substance abusing adolescents. The modest results in this study may be due to the difficulty in transporting MST from the program developers to the supervisors and therapists implementing the program. Although the findings were not entirely consistent, high fidelity in this study tended to be associated with improved clinical outcomes.

      Cost or Cost-Benefit: (Schoenwald, Ward, Henggeler, Pickrel, and Patel, 1996)

      A study was completed to determine the monetary costs of MST during the 11-month period from referral into the program to the six-month follow-up. The total cost of services in the US condition during the 11-month period was $198,729. The total cost of seeing youth in the MST condition was $298,724 (this includes MST program costs + costs of mental health and substance abuse services). Costs per youth were $5,063 for youth in the MST condition and $3,369 for youth in the US condition. However, based on the clinical outcomes in this study, a 46% reduction in incarceration days and a 64% reduction in hospitalization/residential treatment, the costs of implementing the MST program are nearly offset by the savings in incarceration costs. Since the average incarceration cost is $100/day, the decrease in days incarcerated resulted in a $48,200 savings. In addition, the cost of MST compares favorably to the estimated lifetime costs of untreated delinquency and drug abuse which range from $309,000 to $1 million.

      Four-Year Follow-up of Drug Outcomes - Charleston County, South Carolina (Henggeler, Clingempeel, Brondino, and Pickrel, 2002)

      Evaluation Methodology

      Design: This analysis examines the 4-year outcomes from the randomized clinical trial of MST with 118 juvenile offenders meeting formal diagnostic criteria for substance abuse or dependence. Eighty (43 MST and 37 usual services) of the 118 adolescents who participated in the original study completed the follow-up assessment. Between-group differences were determined at time 5 (T5) by comparing mean scores or percentages of the participants in the MST and usual services conditions on each of the dependent measures. Attrition analyses showed that study dropouts and completers did not differ significantly on the measures assessed. Comparisons between the MST and usual services participants at baseline showed two significant differences. MST participants were older and reported more frequent use of marijuana.

      Sample: The average age of the participants at follow-up was 19.6 years; 76% male, 60% African American, and 40% were Caucasian. Approximately 48% had not obtained a high-school education or GED and 12% had completed some college or technical school beyond high school.

      Measures: Adult criminal activity was measured through youth self-reports on the Self-Report Delinquency Scale (SRD) and computerized arrest records. Drug use was assessed through self-report and urine and head hair samples. Psychiatric symptoms were measured by the Externalizing and Internalizing scales of the Young Adult Self-Report (YAS).

      Analysis: Multivariate analyses of covariance (MANCOVAs) were conducted on measures of (1) aggressive criminal behavior, (2) property crimes, (3) self-reported illicit drug use, (4) psychiatric symptoms to determine the differences between the MST and usual services groups at T5. Chi-square analyses were conducted on the biological drug use indicators (i.e., no positive test versus any positive test).

      Outcomes

      MST participants showed a 75% reduction in convictions for aggressive crimes since the age of 17 years and reported committing significantly fewer aggressive crimes during the past 12 months, compared with the usual services group. There were no significant differences in self-reported drug use between the two groups. However, the biological measures showed young adults in the MST condition had significantly higher rates of marijuana abstinence (55% versus 28%) than did their usual services counterparts. There were no significant differences in psychiatric symptoms between the two groups.

      Moderator analyses showed that the impact of treatment did not vary as a function of demographic characteristics, comorbid psychopathology, or initial (T1) levels of drug use and criminal behavior.

      Outcomes - Brief Bullets

      • MST participants showed a 75% reduction in convictions for aggressive crimes and reported committing fewer aggressive crimes at the 4-year follow-up.
      • At the 4-year follow-up, adults in the MST condition had significantly higher rates of marijuana abstinence (55% versus 28%) than did their usual services counterparts.

      Limitations: The primary limitation of this study is that only 68% of the original sample was assessed at the 4-year follow-up. Therefore, the possibility exists that the findings might be different if the research dropout rate was lower. Although analyses comparing characteristics between completers and dropouts revealed no significant differences, these subsamples could still differ on unmeasured characteristics that might have influenced the findings.

      Norway Replication Study (Ogden and Halliday-Boykins, 2004)

      Evaluation Methodology

      Design: This study followed a 2 (treatment type: MST vs. Child Welfare Services (CS)) x 2 (time: pretreatment, post-treatment) x 4 (county municipality) mixed factorial design, with random assignment to treatment conditions. One hundred adolescents and their families from four counties in Norway, referred to treatment for antisocial behavior, participated in this study. A weighted randomization procedure was utilized to assign families to the treatment or control condition, with each family having a 6/10 chance of receiving MST and a 4/10 chance of receiving the usual CS services. This resulted in 62 families being assigned to MST and 38 families to CS. Assessments were conducted at study entry and after termination of MST treatment (approximately 6 months after intake). Comparison of the two groups at baseline showed CS caregivers were more likely than MST caregivers to be divorced, and MST caregivers were more likely to be married to someone other than the child's biological parent. These differences had no moderating effect on the outcomes.

      Four families dropped out of the MST program early in the treatment, but were replaced with new families. In addition, 4 families withdrew from the study prior to the post-treatment assessment, resulting in a 96% retention rate. Analysis of attrition was not possible because the government-approved informed consent allowed dropouts to have their data expunged from research records.

      MST for youths with serious antisocial behavior was implemented as detailed in the MST treatment manual with no major modifications to the original intervention model. Treatment options for the CS group included foster care and institutional placement. If out-of-home placement was not warranted, less intensive services such as home-based treatment or social work was provided. In this study, 14 youths received long-term institutional placement, 5 were placed in a crisis institution for assessment, 6 were supervised by a social worker in their homes, 7 were given other home-based treatment, and 6 refused the services offered.

      Sample: To be included in the study, adolescents had to (a) be between 12 and 17 years, (b) exhibit serious problem behavior, and (c) have parents that were sufficiently involved and motivated to start MST. The sample consisted of 63 boys and 37 girls, who averaged 14.95 years of age. Ninety-five percent of the caregivers had a Norwegian background. Thirty-nine percent of the sample had been previously placed out of the home, 54% had a history of running away from home, 30% had been suspended from school, and 90% had a history of school truancy.

      Measures: Because Norway's criminal justice system does not make arrests and convictions for youth under 15 years, and offenders under the age of 18 are usually sent to Child Welfare Services rather than prosecuted, archival arrest data is not available for this study. Instead, behaviors for the main outcomes were assessed using multiple informants (parents, teachers, and youths). Youth symptomatology and social competence was measured by caregiver, adolescent, and teacher ratings on the Child Behavior Checklist (CBCL). The Self-Report Delinquency Scale (SRD) was utilized to measure delinquent behavior. Social competence with peers was assessed from adolescent, caregiver, and teacher reports on the Social Competence with Peers Questionnaire (SCPQ). The Social Skills Ratings System (SSRS) was utilized to measure a broad array of social skills. The Family Adaptability and Cohesion Evaluation Scales-III (FACES-III) was completed by both caregivers and adolescents. This instrument measured two key family constructs: cohesion and adaptability. This study also provided assessed out-of-home placement and family satisfaction with the services they received.

      Analysis: ANOVAs and chi-square analyses were conducted to evaluate between and within group differences on the measures collected during the pretreatment and post-treatment assessments.

      Outcomes

      Based on combined caregiver, youth, and teacher reports, youths in the MST condition demonstrated a significant decrease in internalizing behavior and a marginally significant decrease in externalizing behavior (p=.07) at post-treatment, compared with youths in the CS condition. Likewise, MST youths demonstrated a significant increase in social competence, compared to CS youths. There were no significant between group differences on family functioning measures. However, family cohesion increased significantly over time within the treatment condition. MST youths were maintained in the home significantly more often than CS youths. Of those at home during the pretreatment assessment (n=84), 90.6% of MST youths were also at home during the post-treatment assessment, compared with 58.1% of CS youth.

      Follow-up Two Years After Intake (Ogden and Hagen, 2006)

      The follow-up sample consisted of 75 participants. One of the four sites was dropped from the analysis because of poor fidelity, thus this is not an intent to treat analysis. The specific goals of the long-term follow-up were to investigate whether MST was successful in preventing out of home placement and examine reductions in behavior problems, such as delinquency. MST participants were less likely to have been placed out of the home than were their RS (received regular child welfare services) counterparts. This was especially true for boys and older MST participants. At the two-year follow-up, MST youths self-reported less delinquency than RS youths, parents reported fewer behavioral problems on the CBCL total problem scale and less internalizing, and teachers reported fewer behavior problems, less internalizing and less externalizing problems.

      Non-significant differences were reported by youth on the total problem scale of the YSR and the YSR Externalizing and Internalizing scales, as well as the parent reports on the CBCL Externalizing.

      Outcomes - Brief Bullets

      • Youths in the MST condition demonstrated a significant decrease in internalizing behavior and a marginally significant decrease in externalizing behavior (p=.07) at post-treatment, compared with youths in the CS condition.
      • MST youths demonstrated a significant increase in social competence compared to CS youths.
      • MST youths were maintained in the home significantly more often than CS youths.
      • At two-year follow-up, MST youth compared to comparisons reported less delinquency, parents reported fewer behavior problems and internalizing, and teachers reported fewer behavior problems, internalizing and externalizing problems.

      Generalizability: This study shows MST to be effective for adolescents with serious behavior problems in Norway. Findings from this study suggest that this treatment model's success is not unique to American populations. Gender differences were also examined showing that after treatment similarities between girls and boys far outnumbered their differences. Specifically, girls showed greater improvement than boys on externalizing problems and self-reported delinquency. According to teacher ratings, MST was equally beneficial for boys and girls. No gender difference was found on out-of-home placement (Ogden & Hagen, 2009).

      Notes: The community services available to the control group, to which the MST group was compared, are much more comprehensive and treatment-oriented than the services typically available to juvenile offenders in previous MST research. The more modest treatment effects obtained in this study, compared to other evaluations, may be attributable to the nature of the usual services condition.

      Gender differences in MST outcomes (Ogden and Hagen, 2009)

      This analysis uses students from the previous program evaluation to look at gender differences in treatment outcomes.

      Sample: This study used data from 2 previous studies in Norway. The first was an RCT in which 100 adolescents were randomly assigned to either MST (n=62) or regular services (n=38). An additional group of 55 non-randomized adolescents received MST and participated in another study during the second year of program operation and were added for the purpose of studying the sustainability of program effectiveness. The current study included the 117 youth who received MST treatment in the program's first and second year of operation. Of these, 41 were girls and 76 were boys (65%). Adolescents ranged in age from 12-17 years. While somewhat fewer of the girls' caregivers were married or cohabiting (54%) compared to boys' caregivers (62%), the difference was not statistically significant. There were no significant differences on girls' and boys' caregivers' mean age (41.26 years) and family income. At intake to treatment, 91.3% of the adolescents had been living at home with their caregivers for the last 6 months. No gender differences appeared regarding living situation at intake.

      Measures: Adolescents' behavior problems were assessed with multi-informant ratings from caregivers, teachers and adolescents using the CBCL, the Teacher's Report Form (TRF) and the Youth Self-Report (YSR). Youth alcohol and drug use was measured by the Personal Experience Inventory, which was completed by the youth themselves, as was the self-report delinquency scale. A subscale from the Family Adaptability and Cohesion Evaluation Scale was used to assess family cohesion. Caregivers' satisfaction with the MST treatment was measured using the Family Satisfaction Survey. Finally, the youth's place of living was reported by both parents and intake teams at intake and again at treatment termination.

      Analysis: To test for gender differences at intake, chi-square tests and one-way ANOVAS were run. Four MANOVA models were run to test for gender differences in behavioral improvement following treatment.

      Outcomes
      At intake, girls and boys looked far more similar than different, although some differences were apparent at posttest. Girls were rated by their parents as presenting fewer externalizing problems than boys at post-treatment, after controlling for their wave 1 scores. This suggested that girls improved more than did boys on this measure. There were no gender differences on parent reports of internalizing or attention problems. Results revealed that girls rated themselves as having significantly more internalizing problems than did boys at the post-assessment, after controlling for their pretreatment scores. Boys, however, scored significantly higher on the self-report delinquency scale than did girls. This suggests that girls improved more regarding self-report delinquency, whereas boys reported greater reductions in self-assessed internalizing problems. No gender differences were found in terms of changes following treatment on the externalizing and attention problem scales of the YSR, on self-reported drug use or out of home placement. According to teachers, boys and girls showed similar levels of behavioral change following treatment.

      Overall, although girls present a problem profile different than boys, and risk factors are somewhat different, MST is effective regardless of gender.

      Canada Replication Study (Leschied and Cunningham, 2002)

      Evaluation Methodology

      Design: This study employed an experimental design whereby each of the 411 referred youth from four Canadian communities were randomly assigned to either the MST group or the usual services group, which functioned as a control group. Two categories of criteria were used to determine eligibility for MST. The first assessed the appropriateness of a family preservation intervention for the youth and the second verified that the presenting issues of the youth were among those for which MST has been empirically validated.

      Pretesting was administered once the family gave consent and before random assignment was made. Data was collected from youth, parents, and teachers. However for the teacher information there was a low response rate of 57% at intake and 35% at discharge. While the response rate was the same for the two groups, there were also some significant differences between the aggregate scores of the MST and the control groups. Among the 57% of cases for which the teacher information was available, the members of the control group had higher levels of externalizing behavior problems at pretest. The instruments from the intake battery were readministered when an MST case was closed. If the MST case closed prematurely, post-testing was not re-administered. The members of the control group were contacted five months after intake and asked to complete the testing again.

      In total, post-testing for the youth is available in only 62% of the cases and was more likely to be available for the MST group. There was no post-testing available for either a parent or a youth in 49% of control cases and for 28% of the MST group. The members of the MST group had a significantly higher response rate at discharge (71%), compared with the members of the usual services group (52%). Nineteen percent of the MST group dropped out prior to concluding the treatment, however, dropouts did not differ significantly from those who stayed on any of the intake testing. The authors' report no response bias could be identified. Analyses at post-test comparing MST dropouts and MST completers show that MST drop outs performed poorly compared with both the MST completers and the usual services group. The researchers were unable to identify the usual services drop outs.

      All youths were tracked for three years to gauge offending and levels of correctional service utilization at 6, 12, 24, and 36 months after the case was closed. The case was closed for the MST group at the last session with the family. For the control group, the case was considered closed six months after the family signed the consent to participate in the study. At this report 380 youths were tracked at least six month post-discharge, 323 were reached one-year post discharge, 192 were two years post-discharge, and 82 reached three years.

      Sample: To be included in the study, youth had had to be at high risk for committing a criminal offense and meet the eligibility criteria. One of the sites included youth under the age of 12 (27 youth). The average age was calculated for each of the four sites and ranged from 13.9 to 15.3, with an overall average of 14.6 years. Twenty-six percent of the sample was female. Thirteen percent self-identified as aboriginal. Family SES varied in the sample, about one-third were welfare dependent with poor educational achievement and low SES. Also, about 30% of the sample was middle class families with good educations and high incomes.

      In all, 64% of the youth were referred to the MST project by probation officers. Although there had to be evidence of past criminal behavior to qualify for MST, about one third had no record of prior criminal convictions at referral. Thirty percent had been sentenced to at least one sentenced custody stay prior to referral. On average, youth with prior convictions had served 47 days in sentenced custody.

      A clinical profile was drawn from psychometric testing completed by the youth, caregivers, and teachers. According to parent ratings, 84% of youth were over the clinical cutoff for conduct problems and half were over the cutoff for depression. Youth self-reports were only slightly lower, with 61% placing themselves over the cutoff for conduct and 48% for depression. One third of parents placed themselves over the cutoff for caregiver depression and poor family functioning. Teachers rated the youths as low on academic competence and social skills, placing almost all of them at or below the tenth percentile.

      Measures: The following instruments were used as baseline information and to assess the impact of MST on the youth: (1) Standard Client Information System (SCIS); (2) Beliefs and Attitudes Scale; (3) Family Adaptability and Cohesion Scale - II (FACES) - this is a 30-item scale that measures family adaptability (negotiation style, roles, assertiveness, leadership, discipline, child control, rules) and family cohesion (emotional bonding, coalitions, space, family boundaries, shared time/friends, decision-making, and shared activities); (4) Social Skills Rating System; (5) Parental Supervision Index.

      Follow-up data on recidivism and correctional service utilization are collected using a "CR" check of the Canadian Police Information Centre (CPIC). Records are checked at six months and after one, two, and three years post-discharge.

      Analysis: The analyses included a comparison of group means and a survival curve analyses at four follow-up time periods for rates of conviction.

      Outcomes

      Post-test: There were no significant differences between groups in rates of convictions when the means are compared. Likewise, the survival curve did not demonstrate significant group differences regarding convictions. There was no difference in the rate at which the two groups were sentenced to custody during the follow-up or in the length of time before being convicted after being in treatment. Members of the MST group were significantly more likely to be sentenced to a term of open custody and significantly less likely to be sentenced to a term of secure custody, compared to the usual services group. This pattern was observed in three sites. There were no significant differences between groups for the length of time youths spent in custody or for the total number of offenses for which youth were prosecuted.

      MST youth improved significantly on some problems as measured by psychological testing. Compared to the control group, the MST youth improved significantly on parent reports of family adaptability, caregiver depression, and youths' externalizing behavior. The MST group also improved significantly on youth report of internalizing symptoms when compared to the control group. While there were no significant differences between groups regarding parental supervision, these data need to be interpreted with caution because there were significant group differences at intake and because pre/post data are only available for only half the sample.

      Generalizability: The results of this study may be generalized to serious juvenile offenders.

      Limitations: Researchers report that the sample size is too small to detect a large treatment effect. Sample attrition is high, especially for the control group. This may bias the results since the "better" youth may have stayed in the control group receiving usual services, while the worst dropped out. Also, the sample size for youth who were tracked for two and three years after follow-up is very small in the interim evaluation.

      Notes: The Canadian MST program was implemented with a lower budget and less supervision by MST Inc. than previous MST studies. This may have undermined the fidelity of program implementation. Another possible factor that could account for the lack of results in the Canadian study, compared with studies in the U.S., is that the usual services that the control group received were of higher quality than the services youth receive in the U.S.

      The results reported here are from an interim report and does not represent the final report.

      Pilot Study of MST Treatment of Adolescent Sexual Offenders (Borduin, Henggeler, Blaske, and Stein, 1990)

      This was a small study of 16 adolescents arrested for sexual offenses randomized to either MST or individual therapy conditions. Youth in MST received an average of 37 hours, and IT youth received an average of 45 hours of treatment. Recidivism data were collected at an approximately 3-year follow-up. Results showed that fewer subjects in the MST condition had been rearrested for sexual crimes (12.5% vs. 75%), as well as non-sexual crimes (25% vs. 50%). The frequency of sexual rearrests was significantly lower in the MST condition than in the IT condition (0.12 vs. 1.62). The number of rearrests was also lower in the MST group than IT group for non-sexual offenses (0.62 vs. 2.25).

      Sexual Offender Study - Missouri (Borduin, Schaeffer and Heiblum, 2009)

      Evaluation Methodology

      Design
      : A pretest-posttest control group design (with random assignment to conditions and an average 8.9-year follow-up for arrest and incarceration measures) was used to compare the efficacy of MST versus usual community services (UCS). A follow-up period that was long enough to allow for adult arrest data on every youth was selected.

      Families were randomly assigned to treatment conditions. The mean length of treatment/services was 30.8 weeks for the MST participants and 30.1 for the UCS participants; these means were not significantly different. Variability in treatment lengths reflected the individualized nature of the interventions provided in each condition as well as varying degrees of success in meeting treatment goals.

      All families who were referred to the project were initially contacted by phone or a home visit by a research assistant. Families were informed that 2 hour research assessments would be conducted shortly before treatment began and shortly after treatment had ended. The pretreatment assessment session was scheduled at the family's convenience either in their home or in a meeting room at the juvenile office. Self-report instruments and behavior-rating inventories were administered in a random order to the parent(s) and youth. The post-treatment assessment was conducted at the same location and with the same measures as the pretreatment assessment within one week of the completion of treatment. One of the youth's teachers also completed a paper-and-pencil instrument before and after treatment. The teacher was randomly selected and told that the youth was a participant in a study of teen socialization. Follow-up assessments using police and court records of juvenile and adult criminal activity were conducted an average of 8.9 years after treatment had been completed.

      The approach used here is guided by the same principles and uses many of the same evidence-based techniques as in MST for nonsexual offenders but focuses on aspects of a youth's ecology that are functionally related to the problem sexual behavior; reduction of parent and youth denial about the sexual offenses and their sequalae, promotion of the development of friendships and age-appropriate sexual experiences and modification of the individual's social perspective-taking skills, belief system or attitudes that contributed to sexual offending are all important pieces of the intervention with a sexual offender population.

      All of the offenders in the UCS condition received cognitive-behavioral group and individual treatment through the local juvenile court. Youths attended group treatment for 90 minutes twice a week and individual treatment for 60-90 minutes once a week. Group treatment (with 4-6 youths) focused on having each youth: a) accept personal responsibility for his or her sexual offense(s), b) eliminate deviant cognitions, c) learn new social skills (including anger management), d) develop victim awareness and empathy, and e) engage in behaviors and thoughts to prevent relapse. Individual treatment was provided by a different therapist from the group leader and was designed to address barriers and reinforce progress in meeting group treatment goals. Youths also kept personal journals to review during their individual therapy meetings to better understand the connection between their thoughts and behaviors. The interventions were not manual driven; the therapists had discretion in the selection of material and in deciding when youths had completed treatment.

      To sustain the fidelity of MST, therapists received training in the MST model and ongoing quality assurance. Included were an initial orientation, 3-hour weekly group supervision, and individual supervision as needed. The therapists in the UCS condition had been certified as juvenile sexual offender counselors through a university-based training program.

      Youths and their families were referred to the study by juvenile court personnel in a judicial circuit serving two counties with approximately 200,000 people in the Midwestern US; the circuit includes approximately equal numbers of urban and rural residents. Referrals were made consecutively and included all families in which the youth a) had been arrested for a serious sexual offense with a subsequent order for outpatient sexual offender counseling, b) was currently living with at least one parent figure, and c) showed no evidence of psychosis or serious mental retardation. Fifty-one eligible youths and families were referred to and recruited for the study.

      A multi-agent assessment battery was used to obtain outcome measures related to the instrumental and ultimate goals of MST. Instrumental goals, which are theory driven, included improved family relations, improved relations between the youth and his/her peers, and improved grades in school for the youth. Ultimate goals, common to all treatments of juvenile sex offenders, included decreases in rates of post-treatment criminal activity and incarceration.

      Sample: Of the 51 families recruited for the study, 48 families consented to participate (94%). Equal numbers of families were randomized to the MST and UCS conditions. The youths averaged 4.33 previous arrests for sexual and nonsexual felonies. The mean age of the youths was 14 years; 95.8% were boys; 72.9% were white and 27.1% were Black, and among all youths 2.1% indicated Hispanic ethnicity; and 31.3% lived with only one parental figure (always a biological parent). The primary caretaker of the youth included biological mothers (91.7%), biological fathers (6.3%), or stepmothers (2.1%). Families averaged 3.3 children, and 54.8% of the families were of lower socioeconomic status. Analyses of variance and chi-square tests showed no differences in pretreatment criminal histories or demographic characteristics of MST and UCS participants.

      Measures: Psychiatric symptoms in mothers, fathers and youths were assessed by the 53 self-report items of the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI). Behavior problems in youth were assessed through mother and father reports (total score) on the 89-item Revised Behavior Problem Checklist (RBPC). Mother, father and youth perceptions of family relations were evaluated with the 30-item Family Adaptability and Cohesion Evaluation Scales II (FACES-II), which assesses the constructs of cohesion and adaptability. Parent, youth and teacher perceptions of the youth's peer relations were evaluated with the 13-item Missouri Peer Relations Inventory, which measures three factor-analytically derived dimensions of peer relations: emotional bonding, aggression and social maturity. Parent and teacher reports of youth grades were obtained across 5 content areas (English, math, social studies, science and other).

      Youth reports on the Self-Report Delinquency Scale (SRD; 40 items) were used to assess criminal activity during the previous 3 months. Criminal arrest data for the youth were obtained yearly from juvenile office records by research assistants who were uninformed as to each participant's treatment condition. Adult criminal arrest data were obtained from a computerized database by a state employee (also uninformed about treatment condition) who conducted a search by participant name. Each arrest was coded as having taken place during the follow-up period if it occurred after the date of the post-treatment assessment. In addition, each arrest was classified as either a sexual or a nonsexual offense; these categories were mutually exclusive. Information about punitive sentencing also was obtained for each juvenile and adult offense. Juvenile incarceration was measured as the number of days that a youth was placed by the Department of Youth Services in a residential facility. Adult incarceration was measured as the number of days that a participant was sentenced to serve in an adult correctional facility. Because adult sentencing was done prospectively, the length of some participants' sentences exceeded the length of their follow-up period.

      Outcomes
      Analyses were completed to examine whether subjects assigned to MST (n=24) and those assigned to UCS (n=24) differed at pretreatment on measures of individual adjustment, family relations, peer relations, or youth self-reports of delinquent behavior. Averaged caregiver reports indicated that MST youths had more behavior problems than did UCS youths; no other between-groups differences were observed.

      Instrumental Outcomes: Significant Group x Time interaction effects were found in most of the instrumental outcomes. Participants in the MST group showed decreases in their symptoms from pre- to post-treatment, whereas their counterparts in the UCS group showed increases in their symptoms. In addition, parents in the MST group reported a decrease in youth behavior problems from pre- to post-treatment, whereas parents of UCS youths reported an increase in behavior problems. Significant interaction effects were observed for both measures of perceived family functioning, with families receiving MST reporting increases in cohesion and adaptability at post-treatment and parents of UCS youth reporting a decrease in the same areas. Parents, teachers and youths reported increases in emotional bonding and social maturity from pre- to post-treatment for youths in the MST condition, whereas peer bonding and social maturity decreased over time for UCS youths. Parents and teachers of youths receiving MST also reported decreases in youth aggression toward peers at post-treatment; increases were reported for UCS youths. Finally, parents and teachers of youths in the MST condition reported increases in youths' grades at post-treatment, whereas parents and teachers of UCS youths reported decreases in grades.

      Ultimate Outcomes: Measures of ultimate outcome were based on youths' reports on the SRD and on arrest data collected during follow-up. MST youths reported decreases in person and property crimes from pre- to post-treatment, whereas youths receiving UCS reported increases. Additionally, MST participants had 83% fewer arrests for sexual crimes and 70% fewer arrests for other crimes than did their UCS counterparts. MST participants also spent 80% fewer days in detention facilities than did UCS participants. Youths in the MST condition were also at lower risk of rearrest during the follow-up than were UCS participants. By the end of 8.9 years, 75% of participants in the UCS group had been arrested at least once, compared with 29.2% of MST participants. MST participants were at lower risk for sexual offenses and nonsexual offenses during follow-up. By the end of the 8.9 year follow-up, 45.8% of UCS participants had been arrested at least once for a sexual crime and 58.3% had been arrested for a nonsexual crime, compared with 8.3% and 29.2%, respectively, of MST participants.

      Generalizability: Results are limited to juvenile sex offenders. Additionally, over 95% of the sample was male, so generalizability to females is limited as well.

      Limitations: Therapists were not randomly assigned to condition, so it is possible that therapist characteristics such as motivation, commitment, social facility and flexibility were confounded in the study. Researchers were unable to confirm that youths maintained continuous residence in Missouri throughout the entire 8.9 year follow-up period, therefore the possibility that a portion of the youths may have committed crimes in other states cannot be ruled out. Resources were not available to track treatment utilization by participants during the follow-up period, so it is unknown how other treatment services may have contributed to the between-groups differences that were observed in ultimate outcomes.

      Sexual Offender Study- Illinois: (Letourneau, Henggeler, Borduin, Schewe, McCart, Chapman and Saldana, 2009)

      Evaluation Methodology:

      Design: A 2 (treatment type: MST vs. Treatment as Usual for Juvenile Sexual Offenders TAU-JSO) X 3 (time: pretreatment, 6 months, 12 months) factorial design with random assignment of youth to treatment conditions was used. Research assessments were conducted with each youth and his or her caregiver at three points in time: within 72 hours of recruitment into the study (T1), 6 months post-recruitment (T2) and 12 months post-recruitment (T3). During the assessment interview, caregivers and youth jointly completed individual assessment protocols separately.

      One hundred and seventy-eight eligible youth were referred to the study and 131 consented to participate. Two families immediately withdrew from the study (both in TAU-JSO) upon learning they were not randomized into their desired intervention, and two others (one in MST, one in TAU-JSO) were subsequently excluded because of degenerative brain disorders in the youth, leaving a final sample of 127 participants. Random assignment resulted in 36 (54%) probation and 31 (46%) diverted youth in the MST condition, and 35 (58%) probation and 25 (42%) diverted youth in the TAU-JSO condition.

      Participants were 127 youth referred by the county State's Attorney after having been charged with a sexual offense. Inclusion criteria were 1) judicial order for outpatient sexual offender treatment either as part of postadjudication probation or preadjudication diversion, 2) presence of a local caregiver with whom the youth resided, 3) youth age between 11 and 17 years inclusive, 4) fluency in either English or Spanish, and 5) absence of current psychotic symptoms or serious mental retardation.

      The MST therapists worked on a team with individual caseloads of 4-6 families per therapist, using a home-based model of service delivery in which treatment was delivered in home and community settings at times convenient to families. In addition, rotating members of the team were available to respond to crises 24 hours a day, 7 days a week. MST for juvenile sexual offenders is identical to standard MST in its broad and individualized focus on the risk factors associated with juvenile offending generally, but enhances standard MST by addressing aspects of the social ecology that are functionally related to the youth's sexual delinquency. The three main adaptations to MST, briefly, are 1) protocols addressed youth and caregiver denial about the offense, 2) protocols also addressed safety planning to minimize the youth's access to potential victims, and 3) protocols addressed promotion of age-appropriate and normative social experiences with peers.

      All youth in the TAU-JSO condition (n=60) were referred for sexual offender-specific treatment, and the vast majority received services provided by the juvenile sexual offender unit at the juvenile probation department. The youth on probation were directly under the supervision of probation officers and met for sexual offender treatment in groups of approximately 8-10 youth for weekly 60-minute sessions. The sexual offender treatment groups included components that addressed deviant arousal, victim empathy, cognitive distortions, relapse prevention, and family counseling. Key treatment objectives included youth acceptance of responsibility for the offense(s), breaking the sexual offense cycle by increasing youth's awareness of triggers, identification and exercise of internal and external behavioral controls and development of a relapse prevention protocol to reduce the risk of recidivism.

      Of the 127 study participants who provided data, six families dropped out after completing one or more assessments, resulting in a 95% research retention rate. Additionally, some families who remained in the study were unable to complete one or more research assessments for various reasons. Overall, 127 assessments were completed at T1, 124 (98%) at T2 and 120 (94%) at T3. Based upon the original 131 randomized, the attrition at T3 would be 92%. Few youth failed to complete MST (n=6) or TAU-JSO (n=6), and these failures were typically because of youth placement in secure settings.

      Sample: The mean age of youth at pretreatment was 14.6 years. Only 3 (2.4%) participants were female; the majority of youth youth were Black (54%) or White (44%), and 31% of youth indicated Hispanic ethnicity. Thirty-five percent of youth had non-sexual offenses in addition to sexual offenses, ranging from ordinance violations to serious person-related offenses. In the three months before baseline, 11% of the youth had received mental health services and 4% had received substance abuse services.

      Index sexual offense charges included aggravated criminal sexual assault (31%), criminal sexual assault (18%) aggravated criminal sexual abuse (15%), criminal sexual abuse (24%), other sexual offenses (5%), and sexual offenses that were pled down to nonsexual offenses (7%). Police investigative reports indicated that most youth acted alone at the time of their offense (84%) and offended against a single victim (80%). Victim ages ranged from 1 year through adulthood, with most victims falling between 4 and 15 years of age. Most youth (74%) had female victims, 20% had male victims and 6% had male and female victims. Youth offended against relatives (36%), friends including classmates and neighbors (37%), acquaintances (21%), and/or strangers (6%).

      Youth's primary caregivers were mothers (64%), fathers (15%), other female relatives (19%), foster parents (2%) and a male relative (1%). Primary caregivers were partly or fully employed outside the home (52%), unemployed (24%), or homemakers (19%). Many caregivers (41%) had not completed high school, whereas 27% were high school graduates and 32% had completed one or more years of college. At TI, primary caregivers were married (48%), divorced (20%), separated (8%), never married (21%) or widowed (3%). Family economic status varied, with 33% of families earning less than $10,000/year, 38% earning $10,000 to $30,000/year and 28.5% earning $30,000 or more.

      Independent samples t-tests and chi-square analyses were used to examine baseline differences between treatment conditions on the index offense, presence of prior nonsexual offenses, and demographic variables. In no case did a statistically significant between-groups difference emerge.

      Measures: Criminal records from city, state and national sources were accessed to determine index sexual offenses and prior sexual and nonsexual offense charges. In addition, police investigative reports were reviewed for descriptive information on index sexual offenses pertaining to victim gender, age at offense, and relationship to offender as well as whether an offense included penetration, multiple victims, multiple offenders or excessive force.

      Inappropriate adolescent sexual behavior was assessed using two subscales of the Adolescent Sexual Behavior Inventory (ASBI) from both youth and caregiver perspectives. The 5-item (youth) and 9-item (parent) deviant sexual interests subscale taps youth behaviors such as owning pornography, use of sex lines and voyeurism. The 10-item (youth) and 8-item (parent) sexual risk/misuse subscale assesses overt sexual behaviors such as having unprotected sex, being sexually used by others, and pushing others into having sex.

      Youth criminal behavior was measured by the self-report delinquency (SRD) scale. The General Delinquency subscale was used, which includes a wide variety of criminal and delinquent behaviors. Youth substance use was assessed with a subscale of the Personal Experience Inventory (PEI), which combines two items assessing the frequency of adolescent alcohol and marijuana use for the previous 90 days. Youth mental health symptoms were assessed with the Externalizing and Internalizing scales of the parent-reported Child Behavior Checklist (CBCL) and the corresponding Youth Self Report (YSR). The caregiver-reported monthly Services Utilization Tracking form was used to collect youth placement data.

      Analysis: Two-level Mixed-Effects Regression Models were performed using HLM software, with restricted maximum likelihood estimation for continuous outcomes and a Bernoulli model with a logit link function and Laplace approximation of maximum likelihood function for dichotomous outcomes.

      Outcomes:
      MST youth evidenced significantly greater reduction in problem sexual behavior over time, relative to their TAU-JSO counterparts. In contrast to TAU-JSO youth, participants in the MST condition reported significantly greater reduction in delinquent behavior and decreased substance use from T1 to T3. The percentage of MST youth reporting delinquent behavior decreased by about 60% from T1 to T3, whereas the corresponding decrease for youth in the TAU-JSO condition was 18%. Similarly, although the percentage of MST youth who reported substance use decreased by about 50% from T1 to T3, the percentage of substance using youth in the TAU-JSO condition increased by 65% during this same time. MST youth also evidenced significantly greater reduction in self-reported externalizing symptoms over time compared to their TAU-JSO counterparts. Finally, the probability that an MST youth was in an out-of-home placement during the past 30 days remained approximately 7% through the 12 months post-recruitment. For youth in the TAU-JSO condition, the probability of being placed increased from 8% to 17% during the course of the follow-up.

      Mediation: In a mediation analysis of the sexual offender data, Henggeler et al. (2009) demonstrated that caregiver follow-through on discipline practices and decreased disapproval with youth’s friends mediated program benefits on sexual deviance, risk taking, and anti-social behavior.

      Generalizability: Results are limited to juvenile sex offenders and males (since only 3 participants were female).

      Limitations: A small portion (5%) of otherwise eligible youth was excluded from the study because they were initially sent to restrictive placements; the findings do not necessarily generalize to the most serious juvenile sexual offenders. Research assistants were often not blind to treatment conditions. Due to the relatively short one year follow-up period, researchers were unable to include sexual reoffending as a key outcome variable.

      Midwestern State Study (Timmons-Mitchel, Bender, Kishna, and Mitchell 2006)
      This is the first randomized trial with juvenile offenders in the U.S. conducted without direct oversight by the model developers.

      Evaluation Methodology

      Design
      : A 2 (treatment condition: MST vs. TAU) x 3 (time: pretreatment, immediate post-treatment, and 6-month post-treatment follow-up) mixed factorial design was used to evaluate functioning. Recidivism was tracked through an 18-month post-treatment follow-up. Participants were 93 youth who appeared before a family county court in a Midwestern State between October, 1998, and April, 2001. 48 youths were randomly assigned to the MST condition and 45 youth were assigned to the TAU condition. Youth were recruited for participation if they met the following inclusion criteria: (a) a felony conviction, (b) a suspended commitment to the Department of Youth Services incarcerating facility, and (c) parents' consent to participate. All youth were either on probation at the time of the study or had been on probation previously.

      Parents or legal guardians of youth meeting the study inclusion criteria were asked to consent to random assignment to either MST or TAU. The court agreed to randomize (into the MST or TAU conditions) families in which caregivers and youths agreed to participate in the study. Both parents and youth provided informed consent, which was obtained either by court personnel or by the MST supervisor. Overall, 89% of eligible participants who met inclusion criteria agreed to participate in the study (n=105). If parents or guardians did not agree but were eligible for MST, it was at the discretion of the court whether to assign them to MST without study participation.

      Randomization was accomplished by having the court administrator flip a coin. Overall, 89% of participants who met inclusion criteria agreed to participate in the study and 89% of participants completed the study (i.e., 11% of study participants dropped out resulting in a final sample of 93 participants).

      Sample: 93 youth participated in the study.The mean age of all youths was 14.1 years at the time of enrollment in the study. Twenty-two percent of the participants were female and seventy-eight percent were male. The racial composition of the sample was as follows: 15.5% African American, 77.5% European-American, 4.2% American Hispanic and 2.8% biracial. There were no statistically significant between-group differences with respect to race or sex. There were also no statistically significant between-group differences on court-related variables such as age at first offense, number of pre-treatment offenses, number of pre-treatment misdemeanors, and number of pre-treatment felonies.

      Measures:

      Official charge data
      : The county family court keeps detailed information regarding juvenile arrests. The recidivism analyses in this study were based on those charges for which the youth was formally arraigned following discharge from treatment (for the MST group) or at 6 months post-recruitment (for the TAU group). Charge data were examined through 24-month post-recruitment for both groups. Despite the level of detail in the court record concerning rearrests, few details were available on the specific type of new charge; however, each charge was designated as either a misdemeanor or a felony.

      CAFAS
      : Ratings for the Child and Adolescent Functional Assessment Scale (CAFAS) were made corresponding with the beginning of treatment, discharge, and 6 months following discharge for MST youth. For TAU youth, ratings approximated timing of administration for MST youth (i.e., baseline, 6-month post-recruitment, and 12-month post-recruitment). The CAFAS measures youth functioning in eight areas: school and work, home, community, behavior, substance use, and thinking. For each subscale, the child receives a score of 0, 10, 20, or 30. A score of zero indicates no or minimal impairment, 10 indicates mild impairment, 20 indicates moderate impairment, and 30 indicates severe impairment. A total score based on the summation of the subscales reflects overall youth functioning. The range of possible scores on the CAFAS is 0 to 240. The higher the CAPAS score, the greater the functional impairment.

      Brief subscale descriptions provided in the current edition of the CAFAS manual are as follows: (a) School/Work: ability to function satisfactorily in a group education environment, (b) Home: extent to which youth observes reasonable rules and performs age appropriate tasks, (c) Community: respect for the rights of others and their property and conformity to laws, (d) Behavior Toward Others: appropriateness of youth's daily behavior, (e) Moods/Emotions: modulation of the youth's emotional life, (f), Self-Harmful Behavior: extent to which the youth can cope without resorting to harmful behavior or verbalizations, (g) Substance Use: youth's substance use and the extent to which it is disruptive, and (h) Thinking: ability of youth to use rational thought processes.

      To provide a standardized method of CAFAS assessment, research assistants used court records to rate MST and TAU youth at baseline, at immediate posttreatment (for MST youth) or 6-month post-recruitment (for TAU), and at 6-month post-treatment (for MST youth) or 12-month post-recruitment (for TAU youth).

      Analysis: Relative odds ratios were calculated for the likelihood of rearrest. Binary logistic regression was conducted to compute the relative risk of rearrest in the TAU versus the MST group. The survival analysis was conducted using a Fleming-Harrington test that weighted offenses later in time more heavily than offenses earlier in time. The rationale for using this weighting scheme with post-treatment arrest data derives primarily from knowing that rates of reoffending typically increase over time as active supervision of youths' activities decreases.

      Average CAFAS scores were calculated for the sample. For purposes of this study, two subscales measuring Self-Harm Behavior and Thinking were eliminated from analyses due to the lack of frequency with which items on these scales were endorsed at the time of initial rating. General linear modeling repeated measures were used to examine changes in the remaining six CAFAS subscale scores over time. The CAFAS total score is not presented as there is limited evidence that this score presents information separate from that already covered in the subscales. To minimize the effect of multiple tests made on the data, alpha was set at .008. Using the adjusted alpha, time by interaction effects were tested.

      Outcomes

      At the 18-month post-treatment follow-up, the recidivism rate for the MST group (66.7%) was significantly lower than the overall recidivism rate for the TAU group (86.7%). Youth in the MST group were also arrested and arraigned for significantly fewer offenses. There were no significant between-group differences in the percentage of felonies versus misdemeanors. Youths in the TAU group were 3.2 times more likely than youths in the MST group to be rearrested. For youth with at least one rearrest, the average time to first arrest was 135 days for youths in the MST group and 117 days for youths in the TAU group, a nonsignificant difference.

      With regards to youth functioning, both groups evidenced improvement in functioning over time, with the MST CAFAS scores significantly better on four of six subscales: home, school, community, and moods and emotions. The difference between the groups was nonsignificant for substance use and behavior towards others.

      Limitations: The study consisted of a very small sample (n=95) which may obscure possible mediators. In addition, the effects were non-significant for two measures, one of which (substance use) correlates highly with involvement in the criminal justice system.

      Study 13

      Butler, S., Baruch, G., Hickey, N., & Fonagy, P. (2011). A randomized controlled trial of Multisystemic Therapy and a statutory therapeutic intervention for young offenders. Journal of the American Academy of Child and Adolescent Psychiatry, 50, (12), 1220-1235.

      The main goal of this study was to evaluate whether Multisystemic Therapy (MST) is more effective in reducing youth offending than an equally comprehensive management protocol called Youth Offending Teams (YOTs). This study can be seen as true independent evaluation since it was conducted without the program developers close involvement. Whereas most other MST evaluations were conducted in the U.S., this study was fielded in the United Kingdom.

      Design:
      ,
      Recruitment /Sample size/Attrition:
      , For the recruitment process, this study used referrals from two local youth offending services in North London. Young persons were included in the study if they were between 13 and 17 years of age; living in the home of and being brought up by a parent or principal caretaker; and being on a court referral order for treatment, supervision, or following imprisonment. Youth were excluded if they were a sex offender; presented only with substance misuse; were diagnosed with a psychotic illness; or posed a risk to research personnel. A total of 478 young persons were referred to the study team, of whom 370 (77%) were excluded because they could not be contacted, refused to consent to assessment, or did not meet the inclusion criteria. The remaining 108 participants were randomized into Multisystemic Therapy (MST) treatment group (n = 56) or Youth Offending Teams (YOT) control group (n = 52). For primary outcome measures, one participant was excluded from the MST group “due to lack of evidence of offence at intake” (p. 1222) (attrition of < 1%). For secondary outcome measures, 3 participants in the MST group and 1 participant in the YOT group did not complete the questionnaires (attrition of 4%).

      Study type/Randomization/Intervention:
      , The study employed a randomized control trial design. The MST team comprised three therapists and a supervisor. The therapists had low caseloads, usually visited the families at least 3 times per week, and were available by telephone to support them 24 hours per day and 7 days per week. The lengths of the interventions ranged from 11 to 30 weeks (mean = 20.4 weeks). Students in the YOT control group received the usual services. As in MST, YOT interventions are extensive and multi-component and included helping the young person to re-engage in education; help with substance misuse problems and anger management; training in social problem-solving skills, and programs for crime awareness. The YOT treatments were delivered by professional social workers, therapists, or probation officers. During the intervention period, participants in the YOT group received approximately 21 professional appointments. There are two key differences between MST and YOT. 1) In contrast to YOT, MST is delivered in a family context by a single person. 2) There is no overarching model or set of principles that governs the selection of treatments in YOT, which could be compared to those in MST. Thus, YOT interventions are offered on an “as needed” basis by specialist agencies to which the young person is referred.

      Assessment:
      , The primary outcome measure (offending behavior) was measured at 6-monthly intervals: for the 6 months before randomization, for the 6 months covering the intervention period, and then every 6 months until 12-months after post test (to which the authors refer as an 18-month follow-up assessment). All secondary outcome measures were obtained at baseline and at posttest, after the MST treatment was completed (6 months after randomization).

      Sample Characteristics: The majority of participants were male (82%) and were, on average, 15 years of age. The sample was racially diverse with 34% white, 32% black, 5% Asian, and 24% classified as Mixed/Other. Participants had an average of more than two offenses at intake with more than half the convictions constituting violent offenses. Only a small minority of individuals were living with two parents; more than two-thirds lived with their mothers but not their fathers, and less than 10% with their fathers but not their mothers. Only one-third were in mainstream education. Of the parents, 31% had left school with no academic qualifications; 40% had no vocational qualifications; and 54% were without income. In sum, almost all subjects lived in socioeconomically disadvantaged families.

      Measures:
      ,
      Validity of measurements:
      All measures were borrowed from prior questionnaires for which validity and reliability had been demonstrated. Alpha values of the employed scales are not reported.

      Primary outcome measures:

      • The number of records of offending behavior (count data) was obtained from the National Young Offender Information System (YOIS) database. In addition, a dichotomous variable measured the occurrence of 6-month periods free of any offending behavior.

      Secondary outcome measures:
      Self- and parent-rated symptoms of antisocial behavior, delinquency-linked cognitions, personality functioning, and parenting variables were measured using the following items/scales:

      • Self-Report of Youth Behavior (SRYB): Based on youth’s self report, this scale measured antisocial behavior such as vandalism, theft, burglary, and fraud.
      • Youth Self-Report (YSR) questionnaire: The delinquency and aggression subscales of the YSR were employed.
      • Child Behavior Checklist (CBCL): Was completed by parents or guardians.
      • Antisocial Beliefs and Attitudes Scale (ABAS): Based on youth’s self reports, this scale measured beliefs and attitudes toward standards of acceptable behavior in social and family contexts.
      • Positive Parenting and Disciplinary Practices (PP) measure: This questionnaire was completed by the primary care giver.
      • Subjective Family Image Test (SFIT): Completed by the family, this questionnaire assessed the quality of the emotional bond between adolescent and parent.
      • Antisocial Process Screening Device (APSD): This parent-completed questionnaire measured youth psychopathic traits.
      • Youth’s Involvement with Delinquent Peers (IDP) scale: This parent-completed 16 items scale was adapted from the Youth in Transition Study.

      In addition, a demographic data form was used to gather information regarding participants’ ethnicity and socioeconomic background.

      Analysis: The authors employed multilevel models to account for the hierarchical data structure (measurement points are nested within persons). Both intercepts and slopes of time were allowed to vary randomly across individuals. Depending on the investigated outcome measure, linear, logistic, or Poisson models were used. All models implicitly control for baseline characteristics.

      Intention-to-treat: The study followed the intent-to-treat principle.

      Outcomes

      Implementation fidelity: Therapists that delivered the intervention received thorough training in MST programs and procedures as part of the study. In addition, therapists received weekly supervision from the MST supervisor, as well as weekly 1-hour consultation (via telephone) with an MST outside expert, on-site booster training sessions four times per year, and twice-yearly implementation reviews. The research team closely followed the MST Organizational Manual. In addition, the MST Therapist Adherence Measure (TAM) was used to assess adherence to the nine MST treatment principles.

      Other than to note that YOT youth attended a significantly greater number of appointments than the MST youth, the study does not provide measures of fidelity.

      Baseline Equivalence: The intervention and control group did not differ significantly at baseline on any measured variable.

      Differential attrition: No test for differential attrition was performed. The authors point out that “missing values were not a significant problem in the analysis of the data set for primary outcomes (< 5%) and data for all participants were used for secondary outcomes, although three individuals in the MST and one in the YOT group provided no self-report information” (p. 1225).

      Post-test/Long-term: Due to the reporting of time x group interaction, it is not possible to disentangle post-test and long-term effects, except for instances in which the authors provide these details in the text.

      Primary outcomes:
      , Significant group x time interactions suggest a greater decrease in recorded offenses for youths in the MST group compared to youths in the control group. The number of offenses between the two study groups did not differ at post-test, and 6-month follow-up but became significant (p<.001) at the 12-month follow-up assessment. In addition, a significant group x time interaction was found for participants with 6-month periods free of offenses (p<.001). This effect was more pronounced in the MST group than in the YOT group. A sub-category analysis showed that the group x time interaction for both outcome measures was significant for nonviolent offenses (6-month period free of offenses, p<.005; No. of recorded offenses, p<.02) but not for violent offenses. For example, at the 12 months follow-up assessment only 8% in the MST group compared with 34% in the control group had one record or more of a nonviolent offense during the past 6 months (p<.001).

      Secondary outcomes:
      , Out of 21 tests for secondary outcome measures, 5 (24%) were significant. Significant program effects were observed for measures of aggression and delinquency (p<.05). For all significant findings, the group x time interaction suggested that the problem behavior declined stronger for the MST compared to the YOT group. In addition, a number of significant group differences were found for personality, relational, and cognitive measures. The measure for parent reported psychopathic traits (ASPD) declined substantially more over time in the intervention compared to the control group (p<.02). In addition, positive parenting increased in the MST group but decreased in the control group, resulting in a significant (p<.05) group difference.

      Effect size: The study reported that the effect size of the change over time for the MST group was medium for both aggression (ES = 0.42) and delinquency (ES = 0.64), while effect sizes were small for the YOT group on aggression (ES = 0.09) and delinquency (ES = 0.25). However, the study does not report effect sizes for differences between groups across time.

      Mediating effects: A mediator analysis demonstrated that positive parenting did not account for program related changes in offending behavior among youths. Similarly, adherence to MST standards (based on parent’s independent reports about their therapy) did not mediate the group differences on the primary outcome measure of offense frequency.

      Outcomes – Brief
      Although both the Youth Offending Team (YOT) and the Multisystemic Therapy (MST) interventions appeared highly successful in reducing offending, the key finding of the study was that the MST model reduced significantly more the likelihood of nonviolent offending during the 12-month follow-up period. In addition, a decrease in aggression, delinquency, and psychopathic traits as well as an increase in positive parenting was observed at posttest comparing the MST to the YOT group.

      Outcomes – Brief Bullets

      Compared to the Youth Offending Team (YOT) control group, the Multisystemic Therapy MST intervention produced the following results (Butler, et al. 2011):

      • A significant decrease in nonviolent offenses at the 12-month follow-up assessment.
      • A decrease in aggression, delinquency, and psychopathic traits as well as an increase in positive parenting at posttest.

      Limitations

      • Although attrition was small (< 5%), no test for differential attrition was performed.
      • Alpha values of the employed scales are not reported.
      • Limited generalizability due to a small sample, recruited from only two sites in North London.

      Study 14

      Asscher, J. J., Deković, M., Manders, W. A., van der Laan, P. H., Prins, P. J. M., &
 the Dutch MST Cost-Effectiveness Study Group 4. (2013). A randomized controlled trial of the effectiveness of Multisystemic Therapy in the Netherlands: Post-treatment changes and moderator effects. Journal of Experimental Criminology, 9, 169-187.

      Asscher, J. J., Deković, M., Manders, W. A., van der Laan, P. H., Prins, P. J. M., van Arum, S., &
 the Dutch MST Cost-Effectiveness Study Group 4. (2014). Sustainabilityof the effects of multisystem therapy for juvenile delinquents in The Netherlands: effects on delinquency and recidivism. Journal Experimental Criminology, 10, 227-243.

      Dekovic, M., Asscher, J. J., Manders, W. A., Prins, P. J. M., & van der Laan, P. (2012). Within-intervention change: Mediators of intervention effects during Multisystemic Therapy. Journal of Consulting and Clinical Psychology, 80, (4), 574-587.

      Manders, W. A., Dekovie, J., Asscher, J. J., van der Laan, P. H. & Prins, P. J. M. (2013). Psychopathy as predictor and moderator of Multisystemic Therapy outcomes among adolescents treated for antisocial behavior. Journal of Abnormal Child Psychology, 41, 1121-1132.

      The three articles used the same Dutch sample to examine posttest effects (Asscher et al., 2013), long-term effects (Asscher et al., 2014), mediation (Dekovic et al., 2012), and moderation (Asscher et al., 2013; Manders et al., 2013).

      Design: Adolescents with various types of serious antisocial behavior were referred to the study from multiple community sources across the Netherlands and during the years 2006 to 2010. Of 318 assessed for eligibility, 256 met inclusion criteria, consented to participate, and were randomly assigned to MST (N = 147) or a treatment-as-usual control group (N = 109).

      Assessments took place at baseline, before the start of the program, and about 6 months later at postintervention, and at 1.08 years after pretest (this is called a 2-year followup in the paper). Official recidivism data were collected at 3.06 years (mean length) after pretest. They also occurred monthly during the intervention period. About 12% of the intervention group and 15% of the control group declined to participate in the posttest or could not be located. However, all subjects were used in the analysis.

      Sample Characteristics, : Most of the subjects had a Dutch background (55%). Many belonged to ethnic minorities (34% Moroccan and 32% Surinamese). Half lived in single parent homes, and 50% of the mothers and 35% of the fathers were unemployed. More than half the families lived below minimum income levels. Judicial records showed that 71% had been arrested at least once.

      Measures: Baseline and posttest assessments took place in the homes of the subjects, and “the majority” of research assistants doing the assessments were blind to the assigned condition. Measures came from parent reports, adolescent reports, and observations and showed acceptable reliability. A brief list summarizes the numerous measures:

      • Cognitions based on parent-reported sense of competence and adolescent-reported self-esteem, personal failure, and hostility
      • Parenting based on parent-, adolescent-, and observer-reported positive discipline, inept discipline, and relationship quality
      • Deviant peers and prosocial peers reported by adolescents
      • Externalizing behaviors from the parent-reported Child Behavior Checklist
      • Oppositional defiant disorder and conduct disorder from the parent-reported Defiant Behavior Disorders rating scales
      • Externalizing behaviors from the adolescent-reported Youth Self Report
      • Violent offending and property offending from the adolescent-reported Self-Report Delinquency scale
      • Official recidivism data from the Judicial Registration System, Dutch Ministry of Justice

      Assessments completed within the intervention period were done by phone with an abbreviated set of items for each scale.

      Analysis: Using an intent-to-treat strategy, the study employed three different statistical approaches. First, the analysis examined posttest outcomes for the groups with ANOVA and controls for baseline outcomes. Second, the analysis examined within-intervention trajectories using latent growth models. Third, structural equation models tested for mediation effects.

      Intent to Treat: Given evidence of data missing completely at random, the analysis used all cases with the expectation maximum likelihood algorithm in LISREL.

      Outcomes

      Implementation Fidelity: A Therapist Adherence Measure that the investigators collected monthly from the parents assessed adherence to the nine principles of MST. The mean of 4.36 on a scale from 1 to 5 showed acceptable adherence.

      Baseline Equivalence: No significant baseline differences were found on any of the demographic or outcome variables.

      Differential Attrition: Participants lost to postintervention assessment did not differ significantly on any of assessed variables from those that remained in the study. Also, a test showed that data were missing completely at random, and all participants, including those not completing the posttest, were included in the analysis.

      Posttest: Dekovic et al. (2012) presented results on 1) intervention effects at posttest, 2) within-intervention change, and 3) mediated effects. First, the program significantly improved four of the five posttest measures compared to the control group: parental sense of competence, positive discipline, relationship quality, and externalizing problems. Only inept discipline did not improve. Second, as shown by differences across groups in the mean slopes, the program significantly increased the within-intervention rates of growth in the same four outcomes as above. Effect sizes similarly increased over time. By the end of the sixth month, effect sizes for the four significant outcomes ranged from about .2 to.5. Third, mediation models showed that participation in MST was significantly related to a greater increase in material sense of competence, which in turn predicted an increase in positive discipline. These changes then predicted a decrease in adolescent externalizing. However, a similar model using relationship quality rather than positive discipline did not significantly mediate between the program and externalizing behavior.

      Asscher et al. (2013) found significant improvement in the treatment group relative to the control group for 5 of 6 primary measures: parent-reported externalizing, opposition defiant disorder, and conduct problems, and adolescent-reported externalizing and property offending. Effect sizes ranged from .25-.36. They also found significant program improvement for 9 of 15 secondary measures. The significant outcomes included measures of parent-reported sense of competency, youth-reported hostility, parent-, adolescent-, and observed-reported positive parenting, parent- and observer-reported quality of relationship, observer-reported inept discipline, and adolescent-reported prosocial peers. However, one significant iatrogenic effect emerged for adolescent-reported sense of personal failure. Effect sizes for the secondary measures ranged from .26-.47.

      Asscher et al. (2013) also tested for moderation effects by ethnicity and age, with little evidence of differences across groups. Tests for moderation by gender found that for adolescent cognitions, the treatment had larger (and more positive) effects for boys than for girls.

      Manders et al. (2013) tested for additional moderation effects. They found that MST was more effective than the control in decreasing externalizing problems for the "lower callous/unemotional" and "lower narcissism" group, but not for the "high callous/unemotional" and "high narcissism" group.

      Long-term (Asscher et al., 2014): All effects that were present at posttest are still present at 2-year followup. There were no differences between the conditions in frequency or number of arrests, time to rearrest, or type of arrest, at 6 months and at 2 year followup. At the end of the followup period (average 3.06 years), 63% of the MST group and 53% of the TAU group had been rearrested at least once, but these differences were not significant.

      Limitations

      • Many measures reported by parents, who helped deliver the program
      • One possible iatrogenic effect

      Study 15

      Weiss, B., Han, S., Harris, V., Catron, T., Ngo, V. K., Caron, A., Gallop, R., & Guth, C. (2013). An independent randomized clinical trial of Multisystemic Therapy with non-court-referred adolescents with serious conduct problems. Journal of Consulting and Clinical Psychology, 81(, 6), 1027-1039.

      This independent replication study uniquely recruited U.S. adolescents from a source other than the criminal justice system. Participants were drawn from self-contained behavior intervention classrooms in public junior and senior high schools from a large, southwestern city.

      Design,

      The authors contacted public junior and high schools to recruit adolescents between the ages of 11 and 18 who were enrolled in self-contained behavior intervention (Moderate Intervention Program: MIP) classrooms that are designed for adolescents with conduct problems. Of 213 families with children in MIP classrooms, 164 (77%) provided consent to participate in the study. After baseline measures were collected, 84 adolescents were assigned to the treatment group and 80 were assigned to the treatment-as-usual control group at random. After being allocated to the treatment group, 1 student (1.2%) declined treatment and 2 (2.5%) discontinued treatment soon after enrollment. Outcomes were assessed at baseline, 3 months (mid-program), 6 months (posttest), and 18 months (1-year follow up). Over the course of the study, 3 families in the treatment group (3.6%) and 8 families (10%) in the control group withdrew from the study or could not be located by the 1-year follow up assessment. The authors did not state explicitly how long the program lasted.

      Regardless of program completion, all available data from the 164 randomized adolescents were used in the analysis.

      Sample,

      Participants were enrolled in the 7th through 11th grades at baseline, with a mean age of 14.6 years. The vast majority of adolescents (83%) were male, 60% were black, and 40% were white. Parents or guardians averaged 40.8 years of age, 71% had at least completed high school, and median reported family income was $17,500.

      Measures,

      All measures were obtained from separate interviews for parents and adolescents at a location of their choosing, while teachers were given the assessment materials to complete on their own time. Parents both participated in the program to help their child and provided many outcome measures. However, an additional analysis found that adjusting for a measure of positive impression among parents did not change the results.

      The primary outcomes were adolescent conduct problems as assessed by parent, adolescent, and teacher reports on the Child Behavior Checklist (CBCL) and criminal charges obtained from court records. The CBCL is used to obtain a broad measure of child behavioral and emotional problems, and its 118 items produce separate scales for externalizing and internalizing problems. The authors report that these scales have average 1-week test-retest reliability of .89. Criminal records were obtained with parental and child assent from juvenile court records from 1 year prior to baseline through 2.5 years post-baseline. Charges were coded as status offenses, misdemeanors, or felonies, with the analysis focusing on incidents wherein the adolescent was charged with a felony.

      Secondary outcomes included several areas of conduct problems such as delinquency and drug use that were measured using the Self Report Delinquency Scale (validity and reliability were not reported). School functioning data was also included, and consisted of the student’s average grade across all core academic subjects, school attendance, and the number of days suspended during the study period.

      The authors also detailed the measurement of nine factors related to the study’s risk and protective factors. To assess family relationships, parents and youth completed the Family Adaptability and Cohesion Evaluation Scales III; to assess authoritarian, authoritative, and permissive parenting behavior, the adolescent’s primary caregiver completed the Parental Authority Questionnaire; and to assess parent mental health problems, parents completed the measures of externalizing and internalizing from the Personality Assessment Inventory.

      Analysis,

      Hierarchical linear models were used to analyze program effects, with linear and quadratic terms for time included as random effects and treatment group included as a fixed effect. These models inherently adjust for baseline outcomes. However, the models do not adjust for clustering within the unspecified number of schools.

      Cox proportional hazards models were used to analyze the court data, and estimated whether time to first felony arrest differed by treatment group, adjusting for whether the adolescent had been arrested in the previous year.

      The study adhered to the principles of intent-to-treat, using all available data for all respondents allocated to the treatment and control groups.

      Outcomes,

      Implementation Fidelity: The authors report that therapists’ overall adherence to Multisystemic Therapy principles was moderately high to high, and consistent with the other studies.

      Baseline Equivalence: Of 15 demographic and baseline primary outcome measures, one differed significantly between treatment groups. The treatment group had a higher proportion of parents who had graduated from high school. The authors state that this variable was not related to treatment outcomes, so it was not included in any of the outcome analyses. Also, the study did not appear to test for differences in the other 14 secondary and risk/protective outcomes.

      Differential Attrition: The authors did not assess differential attrition.

      Posttest: Two of 4 primary outcome measures were improved relative to the control group, with intervention-group parents and adolescents reporting greater decreases in externalizing problems; however, teacher reports and arrest data did not show significant treatment effects. Only 1 of 5 secondary outcomes differed significantly between groups, with a quadratic treatment effect for the number of days absent in favor of the treatment group. Among 9 risk and protective factors, 2 showed significant improvement in the treatment group: decreased permissive parenting behavior and decreased parent internalizing mental health problems.

      Study 16

      Fain, T., Greathouse, S. M., Turner, S. F., & Weinberg, H. D. (2014). Effectiveness of Multisystemic Therapy for minority youth: Outcomes over 8 years in Los Angeles County. Journal of Juvenile Justice, 3, (2), 24-37.

      Design,

      The program was evaluated using a QED without randomization of 1,137 juvenile offenders that qualified for MST participation based on the Los Angeles County Juvenile Justice and Crime Prevention Act’s (JJCPA) eligibility criteria. The intervention group consisted of 757 individuals who were accepted into and participated in Los Angeles’ MST program between January 2003 and December 2010, and the comparison group contained 380 youth who were eligible but did not participate in MST between January 2001 and December 2010, most often because of lack of Medicaid coverage. There is little information on the kind of treatment that the comparison group received.

      Data from all participants were tracked for 6 months after qualifying for (in the comparison group) or entering the program (in the intervention group) using automated databases maintained by the Los Angeles County Probation Department, but not all measures applied to all participants. The full sample (100%) had arrest and incarceration data, with fewer having data on completing probation (N= 724, 96% of treatment group; N= 353, 93% of comparison group), probation violations (N= 722, 95% of treatment group; N= 353, 93% of comparison group), completing restitution (N= 477, 63% of treatment group; N= 255, 67% of comparison group), and completing community service (N= 363, 48% of treatment group; N= 153, 40.3% of comparison group). Risk and protective factors targeted by the intervention were only collected from the treatment group beginning in 2004, resulting in 508 participants (67% of treatment group) with data in this area.

      Sample,

      The mean age of program participants was 15.3 at baseline, and almost all youth (96%) had at least one prior arrest. The majority of participating youth were Male (77%) and Hispanic/Latino (about 74%), with a smaller number identifying as African American (about 20%) and very few as White or some other ethnicity (about 7%). Most participants were arrested for violent (30%) or other crimes (43%) that led to their qualifying for MST, with fewer arrested for property (21%) or drug crimes (5%).

      Measures,

      Juvenile justice outcomes, all measured as zero for no and one for yes, included 1) arrests, 2) incarcerations, 3) successful completion of probation, 4) successful completion of restitution, 5) successful completion of community service, and 6) probation violations. All were measured continuously for 6 months after qualifying for MST and were obtained from an automated database maintained by the Los Angeles County Probation Department.

      Five risk and protective factors targeted by the program were measured among the treatment group at baseline and discharge from the program, beginning in 2004. The factors included parenting skills, family relations, network of social supports, success in educational or vocational settings, and involvement with prosocial peers. Performance in each area was rated as satisfactory or unsatisfactory according to criteria specified by MST caseworkers; for example, improvement in parenting skill required parents to demonstrate at least two of the following: 1) increased limit setting, 2) established and enforced consequences, 3) increased monitoring. MST caseworkers who delivered the therapy provided the scores.

      Analysis,

      Logistic regression was used to evaluate all juvenile justice outcomes with race/ethnicity, treatment group, age, gender, and type of offense at recent arrest included as covariates. Race-stratified analyses were also performed, comparing the effects of MST treatment for African American and Hispanic participants. McNemar’s test (paired chi-square) was used to evaluate the significance of pre- to post- changes in risk and protective factors and did not include adjustments for sociodemographic or criminogenic factors.

      The study adhered to the principles of intent-to-treat, analyzing all participants with relevant data in their original condition.

      Outcomes,

      Implementation Fidelity: No measure of implementation fidelity was reported.

      Baseline Equivalence: The treatment and comparison groups were similar at baseline, significantly differing only on ethnicity (MST participants were more likely to be Hispanic). While baseline equivalence was not examined for the study outcomes, similar measures such as having a prior arrest and offense type at last arrest did not differ by group. However, the groups likely differed on unmeasured socioeconomic characteristics that partly determined assignment.

      Differential Attrition: While the study did not examine differential attrition, all subjects were retained for the analysis of arrests and incarcerations. The smaller sample sizes for other outcomes are likely a result of variation in the sentences given to participants at trial.

      Posttest: After controlling for race, age, gender and type of offense, the treatment group showed significant improvement in 3 of 6 outcomes (arrests, incarcerations, and completion of community service) relative to the comparison group. Without the controls, the intervention group had significantly more probation violations than the comparison group.

      Race-specific analysis of these outcomes revealed that the program’s positive effects were observed for Hispanic youth only. While Hispanic MST youth had significantly lower rates of arrest, lower rates of incarceration, and greater odds of completing probation than Hispanic comparison youth, African American MST youth had higher rates of arrest than the comparison group and did not differ significantly on any other outcomes.

      Of the 6 functional areas targeted by the program, all (parenting skills, family relations, network of social supports, educational/vocational success, involvement with prosocial peers) were significantly improved at posttest within the treatment group (though with no comparison to the non-MST group).

      Limitations

      • Used a QED design without random assignment.
      • Ethnicity differed between groups at baseline.
      • No tests for missing data on several of the outcomes.
      • One iatrogenic effect for African Americans and a possible iatrogenic effect for the full sample (without controls).
      • Tests for risk and protective factors examined only the intervention group.
      • Limited generalizability of juvenile offenders in Los Angeles to population of offenders.

      Video

      http://mstservices.com/index.php/resources/videos