Susan G. Pickrel

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.

Multisystemic Therapy Effects on Attempted Suicide by Youths Presenting Psychiatric Emergencies.

OBJECTIVE To evaluate the efficacy of multisystemic therapy (MST) in reducing attempted suicide among predominantly African American youths referred for emergency psychiatric hospitalization. METHOD Youths presenting psychiatric emergencies were randomly assigned to MST or hospitalization. Indices of attempted suicide, suicidal ideation, depressive affect, and parental control were assessed before treatment, at 4 months after recruitment, and at the 1-year posttreatment follow-up. RESULTS Based on youth report, MST was significantly more effective than emergency hospitalization at decreasing rates of attempted suicide at 1-year follow-up; also, the rate of symptom reduction over time was greater for youths receiving MST. Also, treatment differences in patterns of change in attempted suicide (caregiver report) varied as a function of ethnicity, gender, and age. Moreover, treatment effects were found for caregiver-rated parental control but not for youth depressive affect, hopelessness, or suicidal ideation. CONCLUSIONS Results generally support MSTs effectiveness at reducing attempted suicide in psychiatrically disturbed youngsters, whereas the effects of hospitalization varied based on informant and youth demographic characteristics.

Multisystemic therapy treatment of substance abusing or dependent adolescent offenders: Costs of reducing incarceration, inpatient, and residential placement

The development of more effective and less costly family- and community-based services to serve as alternatives to out-of-home placements of children is an important priority in the reform of mental health services for children and adolescents. Within the context of a randomized trial with 118 substance abusing or dependent juvenile offenders, we examined the incremental costs of multisystemic therapy (MST) and related these costs to observed reductions in days of incarceration, hospitalization, and residential treatment at approximately 1 year postreferral. Results showed that the incremental costs of MST were nearly offset by the savings incurred as a result of reductions in days of out-of-home placement during the year. The need to validate effective treatments for youth with serious clinical problems and to link the costs of treatment

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.

Trauma Exposure, Protective Factors, and Mental Health Functioning of Substance-Abusing and Dependent Juvenile Offenders

This study examined the linkages of trauma exposure and protective factors with important aspects of mental health and behavioral functioning in a sample of youth presenting serious clinical difficulties. In general, results suggest that the effects of trauma vary considerably with the nature of the trauma. Specifically, findings indicated that, after controlling for important third variable explanations, violence exposure was linked with adolescent criminal offending, whereas sexual abuse was linked with psychiatric comorbidity. Additionally, several of the demographic and protective factors showed significant associations with measures of criminal activity and mental health. Implications of these findings are discussed and directions for future research are suggested.

Testing Underlying Assumptions of the Family Empowerment Perspective

We examined two underlying assumptions of the family empowerment perspective. The first assumption is that a well-validated family-based treatment that explicitly aims to empower caregivers can do so. The second assumption is that increased caregiver empowerment should be associated with improved youth and family functioning. The data used to examine these assumptions are based on a randomized trial of multisystemic therapy versus usual community services for 118 substance abusing and dependent juvenile offenders. Results provided partial support for the underlying assumptions of the family empowerment perspective. The family-based treatment in comparison with usual services increased caregiver perceptions of empowerment at the service system level, but not at the family level. In addition, increased empowerment at the family and service system levels were associated with improved family relations, but not with decreased youth behavior problems. The conceptual implications and limitations of the findings are discussed.

The contribution of treatment outcome research to the reform of children’s mental health services: Multisystemic therapy as an example

Service system reforms of the past decade have yielded innovations in type, accessibility, and cost of services provided for some children and families with serious problems, but few of the treatments delivered have been empirically evaluated. Rigorous tests of well-conceived treatments are needed to provide a solid foundation for continued reform. Multisystemic therapy has demonstrated efficacy in treating serious clinical problems in adolescents and their multineed families and is an example of the successful blending of rigorous treatment outcome research and service system innovation.

Predictors of Treatment Response for Suicidal Youth Referred for Emergency Psychiatric Hospitalization.

This study evaluated factors that predicted poor treatment response for 70 suicidal youth (ages 10 to 17 years; 67% African American) who received either multisystemic therapy (MST) or inpatient psychiatric hospitalization. Following treatment, suicidal youth were classified as either treatment responders or nonresponders based on caregiver or youth report of attempted suicide. Overall, female gender, depressive affect, parental control, caregiver psychiatric distress, and caregiver history of psychiatric hospitalization were associated with suicide attempts. However, controlling for other variables, only depressive affect and parental control predicted treatment nonresponse. These results suggest the need to adapt existing treatments for suicidal youth to better address problems relating to youth depression.