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Multisystemic Therapy (MST) for Juvenile Offenders

Multisystemic Therapy (MST) for Juvenile Offenders addresses the multidimensional nature of behavior problems in troubled youth. Treatment focuses on those factors in each youth's social network that are contributing to his or her antisocial behavior. The primary goals of MST programs are to decrease rates of antisocial behavior and other clinical problems, improve functioning (e.g., family relations, school performance), and achieve these outcomes at a cost savings by reducing the use of out-of-home placements such as incarceration, residential treatment, and hospitalization. The ultimate goal of MST is to empower families to build a healthier environment through the mobilization of existing child, family, and community resources. MST is delivered in the natural environment (in the home, school, or community). The typical duration of home-based MST services is approximately 4 months, with multiple therapist-family contacts occurring weekly. MST addresses risk factors in an individualized, comprehensive, and integrated fashion, allowing families to enhance protective factors. Specific treatment techniques used to facilitate these gains are based on empirically supported therapies, including behavioral, cognitive behavioral, and pragmatic family therapies.

Descriptive Information

Areas of Interest Mental health treatment
Substance abuse treatment
Co-occurring disorders
Outcomes Review Date: April 2012
1: Monetary benefit-to-cost advantage

Review Date: March 2007
1: Posttreatment arrest rates
2: Long-term arrest rates
3: Long-term incarceration rates
4: Self-reported criminal activity
5: Alcohol and drug use
6: Perceived family functioning-cohesion
7: Peer aggression
Outcome Categories Alcohol
Cost
Crime/delinquency
Drugs
Family/relationships
Social functioning
Violence
Ages 6-12 (Childhood)
13-17 (Adolescent)
Genders Male
Female
Races/Ethnicities American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Outpatient
Home
School
Other community settings
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History Since its inception in 1996, MST for Juvenile Offenders has been provided to more than 75,000 families. More than 700 teams have implemented the intervention in 38 States and internationally in 12 countries. International licensed sites are located in Australia, Canada, Denmark, Holland, Iceland, Ireland, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations Training materials have been translated into Danish, Dutch, Norwegian, and Swedish.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: April 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., Fucci, B. R., Blaske, D. M., et al. (1995). Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology, 63(4), 569-578.  Pub Med icon

Klietz, S. J., Borduin, C. M., & Schaeffer, C. M. (2010). Cost-benefit analysis of Multisystemic Therapy with serious and violent juvenile offenders. Journal of Family Psychology, 24(5), 657-666.  Pub Med icon

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.  Pub Med icon

Supplementary Materials

Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Technical appendix. Olympia: Washington State Institute for Public Policy. Retrieved from http://www.wsipp.wa.gov/rptfiles/04-07-3901a.pdf

Miller, T. R., Fisher, D. A., & Cohen, M. A. (2001). Costs of juvenile violence: Policy implications. Pediatrics, 107(1), e3.  Pub Med icon

Singh, B., Hawthorne, G., & Vos, T. (2001). The role of economic evaluation in mental health care. Australian and New Zealand Journal of Psychiatry, 35(1), 104-117.  Pub Med icon

Outcomes

Outcome 1: Monetary benefit-to-cost advantage
Description of Measures Monetary benefit-to-cost advantage was derived from the Washington State Institute for Public Policy (WSIPP) benefit-cost model, an integrated set of estimates and computational routines that include (1) benefit-to-cost ratios based on monetary estimates of costs associated with crime, (2) formulas for contrasting costs associated with crime and operational costs of delivering treatment programs, and (3) formulas for contrasting relative costs and benefits of treatment programs. Three sets of study measures were used in the WSIPP model:

  • Six categories of county juvenile justice office records and adult criminal arrest data from State police records: murder/manslaughter, sexual, robbery, aggravated assault, property, and drug arrests. These data were retrieved yearly from the end of treatment through an average posttreatment follow-up period of 13.7 years (11.8-15.2 years after treatment; standard deviation = 1.2 years). Estimates of the costs associated with each type of arrest were adjusted to 2008 values using the Consumer Price Index from the U.S. Bureau of Labor Statistics.
  • The estimated costs of providing MST and individual therapy (the comparison intervention). The cost of MST was estimated with data from the budget of a private service organization delivering the intervention in 2008. The cost of individual therapy was calculated by multiplying the reimbursement rate per treatment session in 2008 by the average number of treatment sessions delivered by a family counseling center.
  • Estimates of monetary benefits to taxpayers and tangible and intangible monetary benefits to crime victims. Monetary benefits to taxpayers were estimated from expenditures by public agencies in the State of Washington. Tangible monetary benefits were defined as expenses related to property damage or loss, medical care, mental health care, police and fire services, victim services, and lost productivity. Intangible monetary benefits were defined as out-of-pocket expenses associated with an injury added to the amount of compensatory damages awarded by a jury for lost quality of life associated with nonfatal injuries.
Key Findings A randomized clinical trial was conducted with adolescent offenders (aged 12-17) and their families who were referred by juvenile court. Participants received either MST or individual therapy (i.e., usual community treatment, which consisted of psychodynamic, client-centered, and behavioral therapeutic approaches that focused on personal, family, and academic issues). Data from the average posttreatment follow-up period of 13.7 years were assessed with the WSIPP benefit-cost model to compare the monetary benefit-to-cost advantage of MST and individual therapy. Results indicated that over the follow-up period, the use of MST relative to individual therapy saved taxpayers and crime victims $75,110 per MST participant with one offense per arrest and $199,374 per MST participant with more than one offense per arrest. Also over the follow-up period, the savings to taxpayers and crime victims per dollar spent (benefit-cost ratio) on MST relative to individual therapy was $9.51 per MST participant with one offense per arrest and $23.59 per MST participant with more than one offense per arrest.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent) 69.3% Male
30.7% Female
76.1% White
22.2% Black or African American
1.7% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Monetary benefit-to-cost advantage 3.3 3.3 2.5 3.5 3.7 3.7 3.3

Study Strengths

Criminal arrest data (on which the cost estimates were based) were obtained from county juvenile office and State police records, which are considered gold standard measures for this type of data and have high reliability and validity. Investigators justified the cost calculation assumptions by using standard discounting procedures that have been employed in other cost studies and referencing cost estimates to actual legal costs associated with criminal acts and jury award data. The investigators used methods to enhance fidelity in the trial, and it appears that treatment was delivered as intended. The original study from which the cost data are derived used random assignment (which controlled for many potential confounds), had a high treatment completion rate (79.5%), and had a very high long-term follow-up rate (93.8% of participants in the original randomized sample were successfully located). The cost study used sophisticated data modeling, which was based on an intent-to-treat approach and included all randomized participant data in the analyses; the study also had sufficient statistical power to detect between-group differences.

Study Weaknesses

Although arrest records from all randomized participants were used, some of these participants may have committed crimes in other States, which introduces a degree of uncertainty into the cost estimates. Additional costs associated with cost shifting could not be ruled out because other types of service utilization (e.g., social welfare, mental health, primary care) were not tracked during the treatment period or across the long-term follow-up period. The estimated cost of providing MST was not determined by an independent third party without a financial stake in MST, which raises concerns about potential bias.

Review Date: March 2007

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

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, 60, 953-961.  Pub Med icon

Henggeler, S. W., Melton, G. B., Smith, L. A., Schoenwald, S. K., & Hanley, J. H. (1993). Family preservation using multisystemic treatment: Long-term follow-up to a clinical trial with serious juvenile offenders. Journal of Child and Family Studies, 2(4), 283-293.

Study 2

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

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, 445-453.  Pub Med icon

Study 3

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.  Pub Med icon

Study 4

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, 171-184.  Pub Med icon

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, 431-444.

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, 81-93.

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.  Pub Med icon

Study 5

Henggeler, S. W., Halliday-Boykins, C. A., Cunningham, P. B., Randall, J., Shapiro, S. B., & Chapman, J. E. (2006). Juvenile drug court: Enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology, 74(1), 42-54.  Pub Med icon

Supplementary Materials

Henggeler, S. W., & Borduin, C. M. (1992). Multisystemic therapy adherence scales. Unpublished instrument.

Outcomes

Outcome 1: Posttreatment arrest rates
Description of Measures Archival arrest records were collected from the South Carolina Department of Youth Services approximately 60 weeks after referral to treatment, which was on average, about 46 weeks following completion of MST treatment. In another study, postprobation arrests for the 4 years following MST treatment were obtained from State police records.
Key Findings Compared with youth receiving treatment as usual, youth receiving MST were arrested about half as often in the posttreatment period. Recidivism rates were 42% for the MST-treated youth compared with 62% for youth receiving usual services (p < .05). In a second study, MST was more effective than individual therapy in preventing rearrests for violent offenses during the follow-up period (p < .001).
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 2: Long-term arrest rates
Description of Measures Juvenile and adult criminal arrest records were collected at 4.0 and 13.7 years following MST treatment versus individual therapy (IT) or usual services only.
Key Findings At the end of 4 years of follow-up, the rate of criminal recidivism (rearrest) for the MST completers (22%) was less than one third the overall rate for IT completers (71%). At 13.7 years after treatment, MST participants (then aged 29 years) showed significantly lower rates of criminal recidivism (50%) than comparable youth (81%) (p < .0001).
Studies Measuring Outcome Study 1, Study 2, Study 3
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 3: Long-term incarceration rates
Description of Measures Incarceration histories were collected following treatment from archival databases (e.g., juvenile justice records) and from sentencing information (e.g., days sentenced to confinement).
Key Findings MST participants had on average 73 fewer days of incarceration than youth receiving usual services (p < .006). More than two thirds (68%) of youth in the usual-services group were incarcerated after treatment, compared with only 20% of the MST group. Almost 14 years after treatment, MST youth were sentenced to fewer than half as many days of incarceration as the comparison youth (p < .01).
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)
Outcome 4: Self-reported criminal activity
Description of Measures This outcome was measured using full-scale scores from the Self-Report Delinquency (SRD) scale.
Key Findings In two studies, MST participants had significantly lower posttreatment scores on the SRD than youth in comparison conditions (p < .05 and p < .01, respectively).
Studies Measuring Outcome Study 1, Study 5
Study Designs Experimental
Quality of Research Rating 3.2 (0.0-4.0 scale)
Outcome 5: Alcohol and drug use
Description of Measures This outcome was measured using multimethod assessment of substance use combining self-reports of use during the past 90 days and urinalysis. Mean number of days of use was tabulated for alcohol use, heavy alcohol use (more than four drinks), marijuana use, and polydrug use. Urine screens for cannabis, cocaine, and amphetamines were collected at each measurement point.
Key Findings Posttreatment reports of alcohol and marijuana use and other drug use were less frequent among MST participants compared with youth in the comparison condition, p < .05.

Four years after treatment, higher rates of marijuana abstinence were found among MST participants (55%) compared with young adults in the comparison condition (28%), p < .05.
Studies Measuring Outcome Study 4, Study 5
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 6: Perceived family functioning-cohesion
Description of Measures This outcome was measured using a self-report measure of parent and youth perceptions of family functioning using the 20-item Family Adaptability and Cohesion Evaluation Scales (FACES-III). Family cohesion assesses the degree of separation or connection of family members to the family.
Key Findings Posttreatment assessments showed that family cohesion increased among families receiving MST and decreased among families in the usual-services condition (p < .05).
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 7: Peer aggression
Description of Measures Peer relations were assessed through adult and youth reports concerning the adolescent's friendships using the 13-item Missouri Peer Relations Inventory (MPRI). Three dimensions were assessed: emotional bonding, peer aggression, and social maturity.
Key Findings Reports of aggression with peers decreased significantly for MST participants, but remained the same for youth in the usual-services condition (p < .05).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent) 77% Male
23% Female
56% Black or African American
42% White
2% Hispanic or Latino
Study 2 13-17 (Adolescent) 67.5% Male
32.5% Female
70% White
30% Black or African American
Study 3 6-12 (Childhood)
13-17 (Adolescent)
82% Male
18% Female
81% Black or African American
19% White
Study 4 13-17 (Adolescent) 79% Male
21% Female
50% Black or African American
47% White
1% American Indian or Alaska Native
1% Asian
1% Hispanic or Latino
Study 5 13-17 (Adolescent) 83% Male
17% Female
67% Black or African American
31% White
2% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Posttreatment arrest rates 3.0 2.5 2.5 3.5 3.0 3.0 2.9
2: Long-term arrest rates 3.5 2.5 2.5 3.5 3.0 3.0 3.0
3: Long-term incarceration rates 3.5 3.0 2.5 3.5 3.0 3.0 3.1
4: Self-reported criminal activity 3.5 4.0 3.0 3.0 2.5 3.0 3.2
5: Alcohol and drug use 3.0 3.0 3.5 3.0 2.5 3.0 3.0
6: Perceived family functioning-cohesion 3.5 3.5 2.5 3.0 3.0 2.5 3.0
7: Peer aggression 3.5 3.5 2.0 3.0 3.5 3.0 3.1

Study Strengths

The authors generally employed widely used measures with fairly well known validity and strong psychometrics in all respects. The investigators used methods to enhance fidelity in the trial, and it appears that treatment was delivered as intended. At the time these studies were conducted, the approaches to handling missing data were state of the art. Similarly, the approaches to data modeling and analysis were well executed and were the best available at the time. Excellent retention of clients in these studies strengthens the findings.

Study Weaknesses

As the authors seem to recognize, there are sometimes problems with computerized legal records (e.g., government agency arrest and incarceration data), but they also are considered by many to be a gold standard. Some studies had inadequate statistical power for assessing psychosocial measures/outcomes, mainly due to participant dropout. In some cases, there were no controls for variation in treatment contact between the interventions.

Readiness for Dissemination
Review Date: March 2007

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Henggeler, S. W., & Schoenwald, S. K. (1998). The MST supervisory manual: Promoting quality assurance at the clinical level. Charleston, SC: MST Services.

Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. E. (1998). Multisystemic treatment of antisocial behavior in children and adolescents. New York: Guilford.

Multisystemic Therapy Readiness for Dissemination (overview document submitted to NREPP)

Schoenwald, S. K. (1998). Multisystemic therapy consultation manual. Charleston, SC: MST Services.

Strother, K. B., Swenson, M. E., & Schoenwald, S. K. (1998). Multisystemic therapy organizational manual. Charleston, SC: MST Services.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
4.0 4.0 4.0 4.0

Dissemination Strengths

The operational manual is thorough, detailed, and logically sequenced. Comprehensive costing and financial sections are provided to support organizational implementation. Initial and booster trainings are available, as well as ongoing organization and quality assurance support. Mechanisms for supervision and coaching are well developed. The supervisory and quality assurance manual provides a complete delineation of both process and outcome measures. Forms are provided for case and fidelity monitoring.

Dissemination Weaknesses

No RFD weaknesses were identified by the reviewers.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Program development start-up fees (includes start-up kit, manuals, and site visit) $2,000 plus travel expenses Yes
Annual program support fees and service fees $19,000-$29,000 per site plus travel expenses Yes
Annual agency and team license fees (includes use of Web-based adherence monitoring and outcome tracking system) $4,000 per agency plus $2,500 per team Yes
5-day orientation training (includes training materials) $850 per participant plus travel expenses Yes
Supervisor orientation training $350 per participant plus travel expenses No
Adherence data collection About $4,500 per year Yes, for some sites (contact the developer)
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

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.  Pub Med icon

Ogden, T., & Hagen, K. A. (2006). Multisystemic Therapy of serious behavior problems in youth: Sustainability of therapy effectiveness two years after intake. Child and Adolescent Mental Health, 11(3), 142-149.

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

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

Contact Information

To learn more about implementation, contact:
Melanie Duncan, Ph.D.
(843) 856-8226
melanie.duncan@mstservices.com

To learn more about research, contact:
Scott W. Henggeler, Ph.D.
(843) 876-1800
henggesw@musc.edu

Melanie Duncan, Ph.D.
(843) 856-8226
melanie.duncan@mstservices.com

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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