Youth in a Difficult World: Multisystemic Therapy

Arguments are waged as to the management of children who attempt suicide, commit crimes or even those who are abandoned and neglected. Our society has impoverished resources to answer such questions and while some hospitals are available, all too often the answer is prison. Research has demonstrated, however, that children do not need to be hospitalized or incarcerated to get the help they need. A home-based model of therapy, called Multisystemic Therapy or MST, offers treatment services to young people and their families in their homes. Youth with serious emotional or behavioral problems, such as antisocial behaviors, substance abuse, delinquency, or severe depression and suicidality, have been successfully treated through MST.

This approach shows a more hopeful and positive approach and focuses on how to help parents assist their children and how to teach young people to deal with their schools and communities. This program has been found to be an effective alternative to hospitalization and to jails.

The magnitude of the problem is this: 1 in 10 children and adolescents suffer from mental illness severe enough to cause some level of impairment.¹

Nonetheless, fewer than 1 in 5 of these ill children receives treatment.² There is heated debate in our society about the proper roles of medications and psychotherapies for children at risk and children already suffering. But, one thing is clear: children who go untreated, suffer, cannot learn, and may not form healthy relationships with peers and family. Some children are placed on a trajectory for jail rather than college at a very early age.

MST is a mental health service that focuses on changing how youth function in their natural settings that is, at home, in school, and in their neighborhoods.^3,4,5 It is designed to promote positive social behavior while decreasing problematic behavior, including delinquency, depression, or substance abuse. MST therapists focus on strengthening the ability of parents or caretakers to raise children who have complex problems. Therapists working in the home identify strengths in the families and use these strengths to develop natural support systems and to improve their parenting. Therapy is approached as a collaboration between the family and the MST therapist. The family sets treatment goals and the therapist suggests strategies to accomplish them.

Specific treatments are used within MST. The interventions are individualized to the family's strengths and weaknesses and address the needs of the child, family, school, peers, and neighborhood. Therapists working in the home have small caseloads and are available 24 hours a day, 7 days a week. Treatment teams usually consist of professional counselors, crisis caseworkers, and psychiatrists or psychologists who provide clinical supervision.

In a series of randomized clinical trials, MST has proven effective in reducing long-term rates of criminal offending in serious juvenile offenders and in reducing their rates of out-of-home placements. For these youths, long term effects of MST even 4 years post-treatment, were found. MST reduced long-term rates of re-arrest by 25 to 70 percent compared with control groups.

MST has recently been found to be an effective alternative to psychiatric hospitalization with children in a psychiatric emergency. In the most recent randomized trial, MST was found to significantly decrease behavior problems, increase family cohesion, and increase school attendance compared with hospitalization. MST also reduced symptoms of internalizing distress and depression. Importantly, families who received MST were significantly more satisfied with their treatment than were families whose children were hospitalized.

In addition, MST was successful in preventing a significant proportion of adolescents from being hospitalized. Further, the use of hospitalization was not offset by increases in the use of other restrictive placement options. Youth in the hospitalization condition had almost double the number of days in other out-of-home placements in comparison with youths in the MST condition.

Studies comparing the costs of MST for serious juvenile offenders to traditional services have found that MST results in costs savings by decreasing out-of-home placement costs and costs of incarceration.

A complete manual for MST is available from Multisystemic Therapy Services (address below). MST has stringent quality assurance mechanisms to assure treatment fidelity. Following the treatment guidelines is critical as research has shown that strong adherence to the model is correlated with strong case outcomes, and poor adherence is associated with substantially poorer outcomes. Training, which is key to the success of the model, is intensive and ongoing. On-site clinical supervision is necessary to ensure that therapists adhere to the MST program.
References

¹ Shaffer D, Fisher P, Dulcan MK, et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(7): 865-77.

² Burns BJ, Costello EJ, Angold A, et al. Data watch: children's mental health service use across service sectors. Health Affairs, 1995; 14(3): 147-59.

³ Henggeler SW, Schoenwald SK, Borduin CM, et al. Multisystemic treatment of antisocial behavior in children and adolescents. New York: Guilford Press, 1998.

⁴ Borduin CM, Mann BJ, Cone LT, et al. Multisystemic treatment of serious juvenile offenders: long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology, 1995; 63(4): 569-78.

⁵ Henggeler SW, Melton GB, Smith LA. Family preservation using multisystemic therapy: an effective alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical Psychology, 1992; 60(6): 953-61.

NIH Publication No. 01-4587

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