Evidence Based Practices Children & Adolescents

1. Evidence Based PracticesChildren & Adolescents National Association of Mental Health Planning & Advisory Councils Judy L. Stange, Ph.D. Executive Director

2. Multi-Systemic Therapy (MST) • Developed in late 1970’s to address limitations in services for serious juvenile offenders • Limitations included • Minimal effectiveness • No accountability of service providers for outcomes • High cost

3. Existing treatments • Did not address complexity of needs • Too individually oriented • Delivered in settings that bore little relationship to the problem being addressed (e.g., clinic setting) • Traditional treatment setting such as residential placement failed to alter the natural ecology to which youth must return

4. Other Populations addressed with MST • ADHD • Severe mood disorders • Bipolar disorders • Anxiety disorders (panic and OCD) • PTSD • Borderline personality disorder

5. Effectiveness of MST • Reduces long-term rates of rearrest by 25-70 percent • Reduces long-term rates of out-of-home placements by 47-64 percent • Reduces psychiatric symptoms and substance abuse • Improves mainstream school attendance, family relations, and consumer satisfaction

6. Theoretical Rationale • Youth antisocial behavior is multi-determined • Linked with characteristics of the youth, his family, peers, school and community contexts

7. MST • Seeks to reduce the risk factors that youth face • Build youth and family strengths (protective factors) • Emphasis on parental empowerment to modify the natural social network of their children

8. MST Interventions • Improve caregiver discipline practices • Enhance family affective relations • Decrease youth association with deviant peers • Increase youth association with prosocial peers • Improve youth school or vocational performance • Engage youth in prosocial recreational outlets • Develop an indigenous support network of extended family, neighbors, and friends to help caregivers achieve and maintain such changes.

9. Techniques based on • Cognitive behavioral • Behavioral • Pragmatic family therapies.

10. Treatment Plan • Developed in collaboration with family • Family driven • Pragmatic • Goal-oriented

11. Why MST Works • MST priorities include removing offenders from deviant peer groups • Enhancing school or vocational performance • Developing an indigenous support network for the family to maintain therapeutic gains. • MST programs have an extremely strong commitment to removing barriers to service access (see e.g., the home-based model of service delivery). • MST services are more intensive than traditional family therapies (e.g., several hours of treatment per week vs. 50 minutes). • MST has well-documented long-term outcomes with adolescents presenting serious antisocial behavior and their families.

12. Risk Factors Low verbal skills Favorable attitudes toward antisocial behavior Psychiatric symptomatology Cognitive bias to attribute hostile intentions to others. Protective Factors Intelligence Being firstborn Easy temperament Conventional attitude Problem solving skills Context - Individual

13. Risk Factors Lack of Monitoring Ineffective discipline Low warmth High conflict Parental difficulties (i.e, drug abuse, psychiatric problems) Criminality Preventive Factors Attachment to parents Supportive family environment Marital harmony Context - Family

14. Risk Factors Association with deviant peers Poor relationship skills Low association with prosocial peers Preventive Factors Bonding with prosocial peers Context - Peer

15. Risk Factors Low achievement Drop out Low commitment to education Various aspects of the schools, such as weak structure and chaotic environment Preventive Factors Commitment to schooling Context - School

16. Risk Factors High mobility Low community support (neighbors, churches, etc) High disorganization Criminal subculture Protective Factors Ongoing involvement in church activities Strong indigenous support network Context – Neighborhood & Community

17. Developmental and Cultural Issues • MST equally effective with African American as with white youth • Equally effective with younger as well as older youth • Family members viewed as full collaborators in treatment, thus increasing likelihood that interventions are appropriate to the family’s cultural values

18. Developmental and Cultural Issues • Building of indigenous family and local support networks reflects the culture of youth and families • MST treatment teams should reflect the cultural makeup of the community being served • Family preservation model of service delivery (e.g., services in home, not agencies) removes access to service barriers, improving likelihood that economically disadvantaged families can participate in treatment

19. Nine Principles of MST • Principle 1: The Primary Purpose of Assessment is to Understand the Fit Between the Identified Problems and Their Broader Systemic Context • Principle 2: Therapeutic Contacts Should Emphasize the Positive and Should Use Systemic Strengths as Levers for Change • Principle 3: Interventions Should Be Designed to Promote Responsible Behavior and Decrease Irresponsible Behavior among Family Members

20. Nine Principles of MST • Principle 4: Interventions should be Present-Focused and Action-Oriented, Targeting Specific and Well-Defined Problems • Principle 5: Interventions should Target Sequences of Behavior within and between Multiple Systems that Maintain Identified Problems • Principle 6: Interventions should be Developmentally Appropriate and Fit the Developmental Needs of the Youth

21. Nine Principles of MST • Principle 7: Interventions should be Designed to Require Daily or Weekly Effort by Family Members • Principle 8: Intervention Effectiveness is Evaluated Continuously from Multiple Perspectives, with Providers Assuming Accountability for Overcoming Barriers to Successful Outcomes. • Principle 9: Interventions should be Designed to Promote Treatment Generalization and Long-Term Maintenance of Therapeutic Change by Empowering Care Givers to Address Family Members’ Needs across Multiple Systemic Contexts.

22. Fidelity • MST treatment integrity is evaluated by • parental ratings of adherence to these principles, • supervisory ratings of adherence, • multiple procedures are used to promote and maintain treatment fidelity (i.e., adherence to the MST treatment principles).

23. Parent-Child Interaction Therapy (PCIT) • Parent-child interaction therapy (PCIT) is a type of behavioral treatment for young children.

24. Parent-Child Interaction Therapy (PCIT) • Parent interacts with their child, while a PCIT-trained therapist in another room whispers instructions for improving communication and interaction with the child into an earphone that the parent wears.

25. Parent-Child Interaction Therapy (PCIT) • Coaching and role playing are also used.

26. Parent-Child Interaction Therapy (PCIT) • Targeted to improve the behavior of children who have temper tantrums, difficulty in school, challenging authority figures, swearing and defiance.

27. Positive behavioral interventions and supports (PBIS) • Uses the principles and techniques of behavioral analysis to produce behavioral change. • Initially developed to treat people with severely aggressive or self-injurious behaviors.

28. Positive behavioral interventions and supports (PBIS) • Evolved into a behaviorally based intervention process that can be used to target individuals as well as entire school communities.

29. Therapeutic foster care • Developed for children and adolescents who have a history of chronic antisocial behavior, delinquency or emotional disturbance. • This type of care is provided as an alternative to hospitalization, incarceration, or different types of group or residential homes.

30. Therapeutic foster care • Children and adolescents with complex physical health problems may be placed in therapeutic foster care (also known as multidimensional treatment foster care, treatment-foster family care, and family-based treatment).

31. Therapeutic foster care • Foster families are carefully trained to provide a structured environment for these children where they can learn social and emotional skills • Focus is on emotional self-awareness, anger management and conflict resolution.

32. Therapeutic foster care • Participants stay with foster families for several months • In certain programs, participants are separated from their usual peer environment and closely supervised in school, at home, and in the community.

33. Therapeutic foster care • May include individual and family therapy • Often the ultimate goal is to reunite the family once functioning is improved