Young People at risk of developing ASPD: the use of multi-systemic therapy as an early intervention within the family

1. Young People at risk of developing ASPD: the use of multi-systemic therapy as an early intervention within the family Dr Simone Fox Chartered Clinical & Forensic Psychologist MST Supervisor Merton & Kingston Dr Juliette Wait Chartered Clinical Psychologist MST Supervisor Reading PD Congress 19th November 2009

2. Aims of Presentation • To think about Personality Disorder from an adolescent perspective • To develop an understanding of the risk factors in the development of antisocial PD • An overview of MST and how it addresses these risk factors

3. Group Exercise • In pairs identify one risk and one protective factors for the onset of behavioural problems in adolescence; • Individual • Family • School • Peer group • Community • Feedback on flipchart

4. Risk & Protective Factors

5. Common findings of 50+ years of research: delinquency and drug use are determined by multiple risk factors: Family (low monitoring, high conflict, etc.) Peer group (law-breaking peers, etc.) School (dropout, low achievement, etc.) Community ( supports,  transiency, etc.) Individual (low verbal and social skills, etc.) Delinquency is a Complex Behaviour

6. Causal Models of Delinquency and Drug Use Condensed Longitudinal Model Prior Delinquent Behavior Family Low Parental Monitoring Low Affection High Conflict Delinquent Peers Delinquent Behavior School Low School Involvement Poor Academic Performance Elliott, Huizinga & Ageton (1985)

7. Theoretical Assumptions Children and adolescents live in a social ecology of interconnected systems that impact their behaviors in direct and indirect ways These influences act in both directions (they are reciprocal and bi-directional) Based on Bronfenbrenner, Haley and Minuchin

8. EcologicalModel Community/Culture Neighborhood School Peers Family Child

9. Implications for Effective Intervention The research on delinquency and substance use suggests that, to be most effective, services should be: Comprehensive and have the capacity to address all of the relevant risk factors present for each youth and family Individualised to the strengths and needs of each youth and family Delivered in the naturally occurring systems and be implemented in “ecologically valid” ways

10. What is MST? Intensive, goal oriented and time limited intervention Community-based, family-driven Targets the multiple causes of anti-social and criminal behaviour in young people Highly structured clinical supervision and quality assurance processes Strong track record of client engagement, retention and satisfaction

11. Who is the target population for MST? Family and key participants in the environment of young people MST “client” is the entire ecology of the young person - family, peers, school, community Age range 11-17 years High risk of out-of-home placement eg. care, custody, residential school Placement risk due to their behaviour at home / school / in the community May be involved with the criminal justice system

12. What is MST? Focus is on families as the solution Focus on empowering the caregivers / parents to solve current and future problems Parents are full collaborators in planning and delivering interventions Assumption - Children’s behaviour is strongly influenced by their families, friends and communities (and vice versa) Works in partnership with a combination of systems (parents, family, peers, school and community) to address risk factors

13. How does MST work? Assessing and understanding the factors contributing to identified problems Having clear goals to work towards Prioritising key factors and interventions Interventions based on techniques that have strong evidence base: Behaviour therapy Parent management training Cognitive behavior therapy Pragmatic family therapies Pharmacological interventions (e.g., for ADHD) Supporting the parent/carer in devising strategies to target factors contributing to the young person’s behaviour

14. How is MST implemented? Single therapist works intensively with 4 families at a time Meetings at least 2-3 times a week Community and home based Out-of-hours service run by the team which is available to families 24 hours a day, 7 days a week Team has 3-4 therapists and clinical supervisor Involvement typically ranges from 3 to 5 months

15. How is MST implemented? Team provides the family with a single point of contact MST team deliver all treatment Typically no services are referred outside the MST team Never ending focus on engagement and alignment with the primary caregiver and other key stakeholders – addressing barriers MST team must be able to have a lead role in clinical decision making for each case

16. MST Quality Assurance System Team comprised of range of professionals – multi-disciplinary/multi-agency Structured training – orientation and regular boosters Frequent professional development planning Weekly clinical supervision and case review Weekly consultation with consultant in USA Research validated adherence process – for therapists and supervisor

17. Traditional models Individual (family) Clinic-based Fixed times High caseloads – less intensive Open-ended Supervision MST Ecological Home-based Flexible/24 hour Low caseloads – 3x weekly + Fixed goal-driven Quality assurance What’s different? NB Not better, just different approach to address a different need

18. Why does it need to be different? • Multi-determined nature of serious antisocial behaviour • Risk factors span the ecology in which the child is embedded • Families with complex problems struggle to access traditional services • High costs of antisocial behaviour – incarceration, placement, victimisation • Therapist adherence predicts outcome

19. Video

20. References • Kazdin A. E., & Weisz, J. R. (1998). Identifying and developing empirically supported child and adolescent treatments. Journal of Consulting and Clinical Psychology, 66, 19-36. • Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (2009). Multisystemic treatment of antisocial behaviour in children and adolescents – 2nd edition. New York: Guildford Press. • www.mstservices.com