Michael J. Brondino

Multisystemic therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination

The effects of multisystemic therapy (MST) in treating violent and chronic juvenile offenders and their families in the absence of ongoing treatment fidelity checks were examined. Across 2 public sector mental health sites, 155 youths and their families were randomly assigned to MST versus usual juvenile justice services. Although MST improved adolescent symptomology at posttreatment and decreased incarceration by 47% at a 1.7-year follow-up, findings for decreased criminal activity were not as favorable as observed on other recent trials of MST. Analyses of parent, adolescent, and therapist reports of MST treatment adherence, however, indicated that outcomes were substantially better in cases where treatment adherence ratings were high. These results highlight the importance of maintaining treatment fidelity when disseminating complex family-based services to community settings.

Mechanisms of change in multisystemic therapy: Reducing delinquent behavior through therapist adherence and improved family and peer functioning.

The mechanisms through which multisystemic therapy (MST) decreased delinquent behavior were assessed in 2 samples of juvenile offenders. Sample 1 included serious offenders who were predominantly rural, male, and African American. Sample 2 included substance-abusing offenders who were predominantly urban, male, and Caucasian. Therapist adherence to the MST protocol (based on multiple respondents) was associated with improved family relations (family cohesion, family functioning, and parent monitoring) and decreased delinquent peer affiliation, which, in turn, were associated with decreased delinquent behavior. Furthermore, changes in family relations and delinquent peer affiliation mediated the relationship between caregiver-rated adherence and reductions in delinquent behavior. The findings highlight the importance of identifying central change mechanisms in determining how complex treatments such as MST contribute to ultimate outcomes.

Multisystemic Treatment of Substance-Abusing and -Dependent Delinquents: Outcomes, Treatment Fidelity, and Transportability

The effectiveness and transportability of multisystemic therapy (MST) were examined in a study that included 118 juvenile offenders meeting DSM-III-R criteria for substance abuse or dependence and their families. Participants were randomly assigned to receive MST versus usual community services. Outcome measures assessed drug use, criminal activity, and days in out-of-home placement at posttreatment (T2) and at a 6-month posttreatment follow-up (T3); also treatment adherence was examined from multiple perspectives (i.e., caregiver, youth, and therapist). MST reduced alcohol, marijuana, and other drug use at T2 and total days in out-of-home placement by 50% at T3. Reductions in criminal activity, however, were not as large as have been obtained previously for MST. Examination of treatment adherence measures suggests that the modest results of MST were due, at least in part, to difficulty in transporting this complex treatment model from the direct control of its developers. Increased emphasis on quality assurance mechanisms to enhance treatment fidelity may help overcome barriers to transportability.

Four-Year Follow-up of Multisystemic Therapy With Substance-Abusing and Substance-Dependent Juvenile Offenders

OBJECTIVE Although several treatments for adolescent substance abuse have been identified as promising by reviewers and federal agencies, treatment effects extending beyond 12 months have not been demonstrated in randomized clinical trials. The primary purpose of this report was to examine the 4-year outcomes of an evidence-based treatment of substance-abusing juvenile offenders. METHOD Eighty of 118 substance-abusing juvenile offenders participated in a follow-up 4 years after taking part in a randomized clinical trial comparing multisystemic therapy (MST) with usual community services. A multimethod (self-report, biological, and archival measures) assessment battery was used to measure the criminal behavior, illicit drug use, and psychiatric symptoms of the participating young adults. RESULTS Analyses demonstrated significant long-term treatment effects for aggressive criminal activity (0.15 versus 0.57 convictions per year) but not for property crimes. Findings for illicit drug use were mixed, with biological measures indicating significantly higher rates of marijuana abstinence for MST participants (55% versus 28% of young adults). Long-term treatment effects were not observed for psychiatric symptoms. CONCLUSIONS Findings provide some support for the long-term effectiveness of an evidenced-based family-oriented treatment of substance-abusing juvenile offenders. The clinical, research, and policy implications of these findings are noted.

HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States.

Summary:Determining rates of HIV transmission risk behavior among HIV-positive individuals is a public health priority, especially as infected persons live longer because of improved medical treatments. Few studies have assessed the potential for transmission to the partners of HIV-positive persons who engage in high-risk activities. A total of 3723 HIV-infected persons (1918 men who have sex with men [MSM], 978 women, and 827 heterosexual men) were interviewed in clinics and community-based agencies in Los Angeles, Milwaukee, New York City, and San Francisco from June 2000 to January 2002 regarding sexual and drug use behaviors that confer risk for transmitting HIV. Less than one quarter of women and heterosexual men had 2 or more sexual partners, whereas 59% of MSM reported having multiple partners. Most unprotected vaginal and anal sexual activity took place in the context of relationships with other HIV-positive individuals. Approximately 19% of women, 15.6% of MSM, and 13.1% of heterosexual men engaged in unprotected vaginal or anal intercourse with partners who were HIV-negative or whose serostatus was unknown. The majority of sexually active participants disclosed their serostatus to all partners with whom they engaged in unprotected intercourse. An estimated 30.4 new infections (79.7% as a result of sexual interactions with MSM) would be expected among the sex partners of study participants during the 3-month reporting period. Eighteen percent of 304 participants who injected drugs in the past 3 months reported lending their used injection equipment to others. In addition to the more traditional approaches of HIV test counseling and of focusing on persons not infected, intensive prevention programs for persons with HIV infection are needed to stem the future spread of the virus.

Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: The Healthy Living Project randomized controlled study

Context:The US Centers for Disease Control and Prevention (CDC) strongly recommend comprehensive risk counceling and services for people living with HIV (PLH); yet, there are no evidence-based counseling protocols. Objective:To examine the effect of a 15-session, individually delivered, cognitive behavioral intervention on a diverse sample of PLH at risk of transmitting to others. Design:This was a multisite, 2-group, randomized, controlled trial. Participants:Nine hundred thirty-six HIV-infected participants considered to be at risk of transmitting HIV of 3818 persons screened were randomized into the trial. Participants were recruited in Los Angeles, Milwaukee, New York, and San Francisco. Intervention:Fifteen 90-minute individually delivered intervention sessions were divided into 3 modules: stress, coping, and adjustment; safer behaviors; and health behaviors. The control group received no intervention until the trial was completed. Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization. Main Outcome Measure:Transmission risk, as measured by the number of unprotected sexual risk acts with persons of HIV-negative or unknown status, was the main outcome measure. Results:Overall, a significance difference in mean transmission risk acts was shown between the intervention and control arms over 5 to 25 months (χ2 = 16.0, degrees of freedom = 5; P = 0.007). The greatest reduction occurred at the 20-month follow-up, with a 36% reduction in the intervention group compared with the control group. Conclusion:Cognitive behavioral intervention programs can effectively reduce the potential of HIV transmission to others among PLH who report significant transmission risk behavior.

Psychiatric comorbidity and the 16-month trajectory of substance-abusing and substance-dependent juvenile offenders.

OBJECTIVES To examine the concurrent correlates of internalizing and externalizing disorders among substance-abusing and substance-dependent juvenile offenders and to determine the association between psychiatric comorbidity and psychosocial functioning of the youths 16 months later. METHOD Participants were 118 juvenile offenders meeting DSM-III-R criteria for substance abuse or dependence and their families. A multisource measurement battery was used to assess drug use, criminal activity, family relations, peer relations, school functioning, and out-of-home placements. RESULTS Comorbidity for externalizing disorders was associated with high rates of antisocial behavior and predicted worse 16-month outcomes than substance abuse alone or substance abuse with comorbid internalizing disorders. For criminal activity and drug use, the presence of internalizing disorders buffered the deleterious effect of externalizing disorders on substance-abusing and substance-dependent juvenile offenders. CONCLUSIONS Even in substance-abusing delinquents, a population already extreme in antisocial behavior, the presence of externalizing disorders indicates high risk for deterioration.

Outcomes of a randomized, controlled community-level HIV prevention intervention for adolescents in low-income housing developments.

Objectives:Youth are increasingly at risk for contracting HIV infection, and community-level interventions are needed to reduce behavioral risk. Design:A randomized, controlled, multi-site community-level intervention trial was undertaken with adolescents living in 15 low-income housing developments in five US cities. Methods:Baseline (n = 1172), short-term follow-up (n = 865), and long-term follow-up (n = 763) risk assessments were conducted among adolescents, ages 12–17, in all 15 housing developments. The developments were randomly assigned in equal numbers to each of three conditions: experimental community-level intervention (five developments); ‘state-of-the-science’ skills training workshops (five developments); and, education-only delayed control intervention (five developments). Results:At long-term follow-up, adolescents living in the housing developments receiving the community-level intervention were more likely to delay onset of first intercourse (85%) than those in the control developments (76%), while those in the workshop developments (78%) did not differ from control condition adolescents. Adolescents in both the community-level intervention (77%) and workshop (76%) developments were more likely to use a condom at last intercourse than those in control (62%) developments. Conclusions:Community-level interventions that include skills training and engage adolescents in neighborhood-based HIV prevention activities can produce and maintain reductions in sexual risk behavior, including delaying sexual debut and increasing condom use.

The relationship of social support to physically abused children's adjustment.

OBJECTIVE This study had three main objectives: First, to assess physically abused childrens perceptions of teacher, peer, and family support; second, to determine whether the levels of perceived support differ according to the persons social role; and third to assess which sources of social support show stronger associations with adjustment in a physically abused sample. METHOD Perceived social support from teachers, families and peers was assessed in a sample of 37 physically abused children using a shortened version of the Survey of Childrens Social Support (Dubow & Ullman, 1989). Child adjustment was indexed by child and parent reports of child depression, anxiety, and anger. RESULTS Analyses indicated that the children rated their families, peers, and teachers highly as sources of social support, with families being rated as the most important source. Hierarchical multiple regression analyses indicated that perceived peer support was significantly negatively related to childrens and parents reports of childrens depression and anxiety. Furthermore, perceived family support was significantly negatively associated with child reported depression. No significant relationships were found between perceived teacher support and symptomatology. CONCLUSIONS Overall, the results suggest that peer and family support are particularly important for physically abused childrens psychological functioning, particularly for internalizing problems.

Effects of quality of life and coping on depression among adults living with HIV/AIDS.

This prospective study examined the effect of maladaptive coping strategies and psychological quality of life (QOL) on depression at two time points in a diverse sample of persons living with HIV/AIDS (N = 85). The use of maladaptive coping strategies to deal with the stress of living with HIV/AIDS, particularly engaging in various kinds of avoidant behaviors, was significantly associated with greater depression at baseline and increased depression at three months. QOL was the single most important predictor of depression. In an effort to develop effective clinical methods aimed at decreasing depression among adults living with HIV, future studies need to focus on improving quality of life and increasing adaptive coping strategies associated with the stress of living with HIV/AIDS.