A Preliminary Investigation of Ethnic Differences in Resistance in Multisystemic Therapy.

Therapy process research suggests that an inverted U-shaped trajectory of client resistance, referred to as the struggle-and-working-through pattern, predicts positive treatment outcomes. However, this research may lack external validity given the exclusive focus on European Americans. This preliminary study explores differences in resistance patterns in a sample of African American and European American juvenile drug offenders and their families (n = 41) participating in Multisystemic Therapy. Resistance was coded from session recordings at the beginning, middle, and end of treatment. There were significant ethnic differences in (a) mean resistance at midtreatment, (b) resistance trajectories, and (c) predictive relationships between resistance trajectories and criminal desistance. Notably, a negative quadratic (i.e., inverted U-shaped) resistance trajectory was more characteristic of European Americans who desisted from crime, whereas a positive quadratic (U-shaped) resistance pattern was more characteristic of African Americans who desisted. There was no relationship between resistance trajectory and later drug abstinence (i.e., cannabis). Within the context of evidence-based therapies, core treatment processes may vary significantly as a function of client ethnicity. We recommend that clinical scientists make efforts to test for ethnic differences in treatment process so that therapies like Multisystemic Therapy can be understood in a more comprehensive and nuanced manner.

Predicting nonresponse to juvenile drug court interventions.

Using data from a recent randomized clinical trial involving juvenile drug court (JDC), youth marijuana use trajectories and the predictors of treatment nonresponse were examined. Participants were 118 juvenile offenders meeting diagnostic criteria for substance use disorders assigned to JDC and their families. Urine drug screen results were gathered from weekly court visits for 6 months, and youth reported their marijuana use over 12 months. Semiparametric mixture modeling jointly estimated and classified trajectories of both marijuana use indices. Youth were classified into responder versus nonresponder trajectory groups based on both outcomes. Regression analyses examined pretreatment individual, family, and extrafamilial predictors of nonresponse. Results indicated that youth whose caregivers reported illegal drug use pretreatment were almost 10 times as likely to be classified into the nonresponder trajectory group. No other variable significantly distinguished drug use trajectory groups. Findings have implications for the design of interventions to improve JDC outcomes.

Estimating the differential costs of criminal activity for juvenile drug court participants: challenges and recommendations.

Juvenile drug court (JDC) programs have expanded rapidly over the past 20 years and are an increasingly popular option for rehabilitating juvenile offenders with substance use problems. Given the high cost of crime to society, an important economic question is whether and to what extent JDC programs reduce criminal activity among juvenile offenders. To address this question, the present study added an economic cost analysis to an ongoing randomized trial of JDC conducted in Charleston, South Carolina. Four treatment conditions were included in the parent study: Family Court with usual community-based treatment (FC, the comparison group), Drug Court with usual community-based treatment (DC), DC with Multisystemic Therapy (DC/MST), and DC/MST enhanced with Contingency Management (DC/MST/CM). The economic study estimated the cost of criminal activity for nine specific crimes at baseline (pretreatment) and 4 and 12 months thereafter. A number of methodological challenges were encountered, suggesting that it may be more difficult to economically quantify frequency and type of criminal activity for adolescents than for adults. The present paper addresses methodological approaches and challenges, and proposes guidelines for future economic evaluations of adolescent substance abuse and crime prevention programs.

Statewide adoption and initial implementation of contingency management for substance-abusing adolescents.

Four hundred thirty-two public sector therapists attended a workshop in contingency management (CM) and were interviewed monthly for the following 6 months to assess their adoption and initial implementation of CM to treat substance-abusing adolescent clients. Results showed that 58% (n = 131) of the practitioners with at least one substance-abusing adolescent client (n = 225) adopted CM. Rates of adoption varied with therapist service sector (mental health vs. substance abuse), educational background, professional experience, and attitudes toward treatment manuals and evidence-based practices. Competing clinical priorities and client resistance were most often reported as barriers to adopting CM, whereas unfavorable attitudes toward and difficulty in implementing CM were rarely cited as barriers. The fidelity of initial CM implementation among adopters was predicted by organizational characteristics as well as by several demographic, professional experience, attitudinal, and service sector characteristics. Overall, the findings support the amenability of public sector practitioners to adopt evidence-based practices and suggest that the predictors of adoption and initial implementation are complex and multifaceted.

If you build it, they will come: statewide practitioner interest in contingency management for youths.

Addressing the science-service gap, we examined in this study the amenability of a large heterogeneous sample of community-based therapists in the state mental health and substance abuse treatment sectors to learn about an evidence-based practice (EBP) for adolescent substance abuse (i.e., contingency management [CM]) when such learning was supported administratively and logistically. Leadership in most (44 of 50) public sector agencies supported practitioner recruitment, and 432 of 543 eligible practitioners subsequently attended a 1-day workshop in CM. Workshop attendance was predicted by organizational factors but not by practitioner demographic characteristics, professional background, attitudes toward EBPs, or service sector. Moreover, the primary reason for workshop attendance was to improve services for adolescent clients; the primary barriers to attendance, for those who did not attend, were practical in nature and not due to theoretical incompatibility. The findings demonstrate a considerable amount of interest practitioners showed in both the substance abuse and mental health sectors in learning about an EBP.

Juvenile drug court: enhancing outcomes by integrating evidence-based treatments.

Evaluated the effectiveness of juvenile drug court for 161 juvenile offenders meeting diagnostic criteria for substance abuse or dependence and determined whether the integration of evidence-based practices enhanced the outcomes of juvenile drug court. Over a 1-year period, a four-condition randomized design evaluated outcomes for family court with usual community services, drug court with usual community services, drug court with multisystemic therapy, and drug court with multisystemic therapy enhanced with contingency management for adolescent substance use, criminal behavior, symptomatology, and days in out-of-home placement. In general, findings supported the view that drug court was more effective than family court services in decreasing rates of adolescent substance use and criminal behavior. Possibly due to the greatly increased surveillance of youths in drug court, however, these relative reductions in antisocial behavior did not translate to corresponding decreases in rearrest or incarceration. In addition, findings supported the view that the use of evidence-based treatments within the drug court context improved youth substance-related outcomes. Clinical and policy implications of these findings are discussed.

Caregiver-therapist ethnic similarity predicts youth outcomes from an empirically based treatment.

The effects of caregiver-therapist ethnic similarity on youth outcomes from multisystemic therapy (MST), as implemented in dissemination sites, were examined. Consistent with hypotheses, findings confirmed that youths whose caregivers were ethnically matched with their therapists demonstrated greater decreases in symptoms, longer times in treatment, and increased likelihood of discharge for meeting treatment goals relative to youths whose caregivers and therapists were not ethnically matched. In addition, for youths whose caregivers were of mixed ethnic heritage, caregiver-therapist ethnic match was associated with greater improvements in psychosocial functioning. Ethnic match effects on both treatment length and discharge success were partially mediated by therapist adherence to MST. This study shows the importance of examining the effects of both client and therapist ethnicity on outcomes from empirically based treatments.

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.

Heterogeneity in youth symptom trajectories following psychiatric crisis: predictors and placement outcome.

The authors examined heterogeneity in symptom trajectories among youths following psychiatric crises as well as the psychosocial correlates and placement outcomes associated with identified trajectories. Using semiparametric mixture modeling with 156 youths approved for psychiatric hospitalization, the authors identified 5 trajectories based on symptoms over the 16 months following crisis: high improved, high unimproved, borderline improved, borderline unimproved, and subclinical. Membership in unimproved symptom groups was associated with less suicidality, younger age, more youth hopelessness, and more caregiver empowerment. Improved symptom group membership predicted long-term decreases in days in out-of-home placements. More important, and in contrast with general impressions from the existing literature, findings suggest that a substantive proportion of youths with serious emotional disturbance sustain high levels of symptomatology following intensive mental health services.

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 MST's effectiveness at reducing attempted suicide in psychiatrically disturbed youngsters, whereas the effects of hospitalization varied based on informant and youth demographic characteristics.

Multisystemic Treatment of Antisocial Adolescents in Norway: Replication of Clinical Outcomes Outside of the US.

BACKGROUND: MST is an intensive home- and community-based intervention for youths with serious antisocial behaviour and other serious clinical problems, which has been effective at reducing out-of-home placements and producing favourable long-term clinical outcomes in the US. The aims of the study were to determine the degree to which these outcomes would be replicated in Norway for youths with serious behaviour problems and to conduct a randomised trial of MST by an independent team of investigators. METHOD: Participants were 100 seriously antisocial youths in Norway who were randomly assigned to Multisystemic Therapy (MST) or usual Child Welfare Services (CS) treatment conditions. Data were gathered from youths, parents, and teachers pre- and post-treatment. RESULTS: MST was more effective than CS at reducing youth internalising and externalising behaviours and out-of-home placements, as well as increasing youth social competence and family satisfaction with treatment. DISCUSSION: This is the first study of MST outside of the US and one of the first not conducted by the developers of MST. The findings replicate those obtained by MST's developers and demonstrate the generalisability of short-term MST effects beyond the US.

Client-level predictors of adherence to MST in community service settings.

This study examined the association of youth and family characteristics with therapist fidelity to an evidence-based treatment provided in real world practice settings. Participants were 233 families that reported on the 66 therapists organized into 16 teams in nine organizations providing multisystemic therapy (MST). Therapist adherence ratings were lower for youths referred for both criminal offenses and substance abuse than for youths referred either for substance abuse or status offenses, and was negatively associated with pretreatment arrests and school suspensions. Adherence ratings were positively associated with educational disadvantage and caregiver-therapist ethnic match and marginally positively associated with economic disadvantage. The findings suggest directions for future research on the implementation of evidence-based treatments in community settings.