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     

Economic Impact of the Statewide Implementation of an Evidence-Based Treatment: Multisystemic Therapy in New Mexico

Several states have made considerable investments into large-scale implementation of evidence-based treatments (EBTs), yet little is known about key success indicators for these implementation efforts such as cost and sustainability. To that end, the present study examined the economic impact of statewide implementation of multisystemic therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cuningham, 2009), a family- and community-based behavioral EBT for serious juvenile offenders in New Mexico. Participants were 1,869 youth who received MST across 23 teams during the study period. We conducted a cost-benefit analysis using metrics from state data sources that compared the cost of MST to its benefits (i.e., avoided expenses from pre- to posttreatment) in two domains: (a) behavioral health services (i.e., Medicaid claims) and (b) juvenile crime (i.e., taxpayer expenses, tangible and intangible expenses to crime victims). MST costs were based on Medicaid claims, which were reimbursed at an enhanced billing rate that was intended to cover expenses for both clinical and implementation (e.g., training, quality assurance) activities. Results suggest that implementation of MST in New Mexico over the 7-year study period may have produced net benefits, through 2 years posttreatment, of more than $4,643 per youth in avoided behavioral health claims and $15,019 per youth through reductions in juvenile crime. Stated differently, every dollar that New Mexico spent on MST appeared to have returned $3.34 for a total benefit of $64.2 million over the course of the study. We discuss implications of these findings for policymakers, administrators, and researchers who are interested in increasing the sustainability of complex EBTs in community settings.     

New developments in electroconvulsive therapy and magnetic seizure therapy

New findings regarding the mechanisms of action of electro-convulsive therapy (ECT) have led to novel developments in treatment technique to further improve this highly effective treatment for major depression. These new approaches include novel placements, optimization of electrical stimulus parameters, and new methods for inducing more targeted seizures(eg, magnetic seizure therapy [MST]). MST is the use of transcranial magnetic stimulation to induce a seizure. Magnetic fields pass through tissue unimpeded, providing more control over the site and extent of stimulation than can be achieved with ECT. This enhanced control represents a means of focusing the treatment on target cortical structures thought to be essential to antidepressant response and reducing spread to medial temporal regions implicated in the cognitive side effects of ECT. MST is at an early stage of development. Preliminary results suggest that MST may have some advantages over ECT in terms of subjective side effects and acute cognitive functioning. Studies designed to address the antidepressant efficacy of MST are underway. As with all attempts to improve convulsive therapy technique, the clinical value of MST will need to be established through controlled clinical trials. This article reviews the experience to date with MST, and places this work in the broader context of other means of optimizing convulsive therapy in the treatment of depression.     

Outcomes from Multisystemic Therapy in a Statewide System of Care

We examined client outcomes from the implementation of Multisystemic Therapy (MST) in a statewide child and adolescent mental health system. Specifically, we examined (1) the validity of therapist-rated MST outcome measures by comparing them to ratings of functional impairment and level of service needs by CAMHD care coordinators, who provide case management and care coordination services, (2) potential client and service predictors of therapist-rated outcomes, and (3) improvement in youth functioning around the time of entry to and exit from MST compared with rates of improvement reported in randomized controlled trials (RCTs) by the developers of MST. Results suggested that therapist-rated MST outcomes were valid indicators of treatment success. Similar to other findings in the MST literature, few client or service characteristics predicted these outcomes. Finally, although MST entry–exit effect sizes were lower than the mean derived from RCTs published by the developers, they were within the 95% confidence interval. Together, these findings support the implementation of MST in complex systems of care with continued attention to quality assurance and ongoing use of data for evaluation.     

Multisystemic Therapy and Functional Family Therapy Compared on their Effectiveness Using the Propensity Score Method

Multisystemic Therapy (MST) and Functional Family Therapy (FFT) have overlapping target populations and treatment goals. In this study, these interventions were compared on their effectiveness using a quasi-experimental design. Between October, 2009 and June, 2014, outcome data were collected from 697 adolescents (mean age 15.3 (SD 1.48), 61.9% male) assigned to either MST or FFT (422 MST; 275 FFT). Data were gathered during Routine Outcome Monitoring. The primary outcome was externalizing problem behavior (Child Behavior Checklist and Youth Self Report). Secondary outcomes were the proportion of adolescents living at home, engaged in school or work, and who lacked police contact during treatment. Because of the non-random assignment, a propensity score method was used to control for observed pre-treatment differences. Because the risk-need-responsivity (RNR) model guided treatment assignment, effectiveness was also estimated in youth with and without a court order as an indicator of their risk level. Looking at the whole sample, no difference in effect was found with regard to externalizing problems. For adolescents without a court order, effects on externalizing problems were larger after MST. Because many more adolescents with a court order were assigned to MST compared to FFT, the propensity score method could not balance the treatment groups in this subsample. In conclusion, few differences between MST and FFT were found. In line with the RNR model, higher risk adolescents were assigned to the more intensive treatment, namely MST. In the group with lower risk adolescents, this more intensive treatment was more effective in reducing externalizing problems.     

Innovations in Family Support: What Are We Learning?

As family support programs develop across the United States through grassroots efforts by families, state demonstration projects, and local initiatives, new opportunities have become available to examine the experiences of families with service delivery systems. In this study, the research team examined key principles of innovative family support and their effects on families with children at high risk for out-of-home placements. The research team used a multi-case study design with indepth participant observation and semi-structured interviews with a purposeful sample of families. The findings on agency implementation and the families' perspectives are described, together with implications for agency change in family support. The findings point to the need for a re-examination of the emerging approaches to family support innovations, including in the context of national policy reform and the agency-based, service delivery system.     

Do haphazard reviews provide sound directions for dissemination efforts?

Comments on The dissemination and implementation of evidence-based psychological treatments: A review of current efforts (see record 2010-02208-010) by Kathryn R. McHugh and David H. Barlow. The lead article in the February–March issue by McHugh and Barlow (2010) emphasized the need for “dissemination and implementation of evidence-based psychological treatments.” The authors identified a number of intervention programs as evidence based and in need of dissemination. One is multisystemic therapy (MST). They claimed that this program is among “the most successful dissemination efforts...pursued by treatment developers” (p. 79). McHugh and Barlow’s (2010) discussion of the implementation of MST in Hawaii is troubling, because it neglected to mention concerns about the perceived lack of cultural sensitivity of the MST program in that state.     

Intensive Home Based Services Within a Comprehensive System of Care for Youth

Within a comprehensive mental health service array for youth, Intensive Home Based Services (IHBS) are designed to meet the needs of youth with significant emotional and behavioral problems in their home communities, avoiding the need for out-of-home services, particularly residential care. We examined youth receiving IHBS as their first service in the state of Hawaii system of care (N = 163) to determine how successful IHBS were in preventing the need for more restrictive services within 12 months of intake. Subsequently, we investigated characteristics that might be predictive of a youth’s need for service intensification within 12 months. Logistic regression analyses found that greater age, level of service need, and functional impairment at intake predicted use of more restrictive services within 12 months of intake, whereas gender, ethnicity, diagnosis, service intensity, and clinician credentials did not. Overall, our findings suggested that IHBS were reasonably successful in preventing residential placements, and provided some basis for determining characteristics of youth likely to require more restrictive placements within a one year period.     

The transportability of multisystemic therapy to Sweden: short-term results from a randomized trial of conduct-disordered youths

This randomized clinical trial assessed the effectiveness of multisystemic therapy (MST) for 156 youths who met the diagnostic criteria for conduct disorder. Sweden's 3 largest cities and 1 small town served as the recruiting area for the study. A mixed factorial design was used, with random allocation between MST and treatment as usual groups. Assessments were conducted at intake and 7 months after referral. With an intention-to-treat approach, results from multiagent and multimethod assessment batteries showed a general decrease in psychiatric problems and antisocial behaviors among participants across treatments. There were no significant differences in treatment effects between the 2 groups. The lack of treatment effect did not appear to be caused by site differences or variations in program maturity. MST treatment fidelity was lower than that of other studies, although not clearly related to treatment outcomes in this study. The results are discussed in terms of differences between Sweden and the United States. One difference is the way in which young offenders are processed (a child welfare approach vs. a juvenile justice system approach). Sociodemographic differences (e.g., rates of poverty, crime, and substance abuse) between the 2 countries may also have moderating effects on the rates of rehabilitation among young offenders. (PsycINFO Database Record (c) 2008 APA, all rights reserved).     

Juvenile Justice Reform in New York State

ABSTRACT

This article describes the work at the Division of Criminal Justice Services of New York State, in collaboration with other state partners, integrating developments in neuroscience, in particularly the understanding of the adolescent brain, into practical, well informed changes to the juvenile justice system in New York State. The process started in earnest in 2010 with a statewide collective impact planning process that included data-driven analysis, extensive interviews with juvenile justice stakeholders, and an analysis of effective practices in New York State and across the nation. This process resulted in the implementation of action steps outlined in a strategic plan for juvenile justice reform entitled Safe Communities, Successful Youth: A Shared Vision for the New York State Juvenile Justice System, released in July 2011. Since that time, we have developed a sophisticated network of juvenile justice stakeholders to come together to work on implementing effective strategies to promote youth success and ensure public safety. Specifically, we have developed statewide metrics and county profiles that allow us to track 235 data points across the juvenile justice system over time so we can get a sense of system effectiveness and pinpoint potential areas of focus. We have also established nine Regional Youth Justice Teams across the State to bring system stakeholders together on a regional basis so that we can more effectively impact change based on the needs of different communities. Finally, we are excited that we will soon be launching a new best practices institute, which will help us to develop and share model interventions for our most vulnerable youth.     

Residential and community treatment services utilized by a sample of youth with severe emotional disturbances

Analyzed case records to determine the costs and service usage patterns for a group of 25 youth randomly selected from the case load of a regional mental health agency. Study participants had extensive histories of publicly supported psychiatric hospitalizations. An average of 36.2 contacts per youth (905 total contacts) with human services providers were documented. Approximately 2 out of every 5 contacts resulted in out-of-home placements. The estimated cost of providing services to the 25 youth exceeded 3 million dollars. The types and costs of treatment services provided to study participants are discussed.     

Controversies in Family Preservation Programs

Summary

This paper examines the controversies over the use of family preservation policies to prevent and treat child abuse and neglect. Policies that aim to preserve families in which child maltreatment has occurred are at least a century old. However, there is renewed interest in such policies, given the dramatic rise in child abuse and neglect reports and a large number of children who spend time in out-of-home placements. New intensive family preservation services were advanced as able to assure the safety of children while working toward a lasting preservation of the family unit. The paper summarizes the research on intensive family preservation services and reports that such programs do not reduce placements nor do they appear to enhance child safety. The paper concludes by proposing that risk assessments and assessments of readiness to change could improve decision-making regarding which families might be aided by family preservation and which children should be protected by terminating their parents' rights.     

Integrating systems of care in california for youth with severe emotional disturbance II: Initial group home expenditure and utilization findings from the California AB377 Evaluation Project

The California AB377 Evaluation Project was established to study the replication of an innovative system of care in three California counties for youth suffering from severe emotional disturbance. Development of the innovative system of care was pioneered in Ventura County, California, and the replications were legislatively enabled through Assembly Bill 377 (AB377). This paper reports evaluative findings about a central goal of the innovative care system: the reduction of use of highly restrictive out-of-home placements though creation and maintenance of coordinated and effective community-based services. Group home facilities are the focus of the evaluation work because these facilities consume the largest proportion of all public expenditures for youth in residential placements in California. More than 10 years of aggregate county and state level monthly expenditure and utilization data are presented. The results indicate that the demonstration counties have generated lower per capita inflation adjusted rates of expenditures and per capita group home placements than California as a whole. The evaluation results provide evidence that an integrated system of care can reduce group home placements. However, the nature, quality and effectiveness of any and/or all alternative services provided remains a topic for further investigation.     

Home-Based vs. Clinic-Based Parent–Child Interaction Therapy: Comparative Effectiveness in the Context of Dissemination and Implementation

Disruptive child behavior disorders remain a major public health issue despite the proliferation of several strong Evidence-Based Practices (EBPs) for these children and their families. This may stem from barriers to treatment facing many families in need, particularly families with low resources. Home-based treatment may be best suited for this population; however, EBPs are not always available or tested as home-based interventions. The current study compares an intensive home-based adaptation of Parent Child Interaction Therapy (PCIT) to the standard clinic-based model in the context of a statewide implementation. As part of the statewide implementation, therapists entered archival data into an online system. Data was gathered for 314 families receiving PCIT, with 181 children in clinic-based PCIT and 133 in intensive home-based PCIT. Consistent with other trials of PCIT, results of the current study indicate that both versions of the therapy were effective in reducing child-behavior problems and increasing parenting skills; however, there were marked differences in attrition. Intensive home-based participants were twice as likely to complete treatment (64.66%) compared to clinic-based participants (33.15%) despite facing more adversity. These results underscore the importance of scientifically-sound adaptations of EBPs, as well as the role of comparative effectiveness studies as a critical tool in the integrative model of intervention science.     

The Departure Status of Youth from Residential Group Care: Implications for Aftercare

Youth departing from out-of-home care settings face numerous challenges as they adapt to new settings or return to placements that have been unsuccessful in the past. Although several thousand youth face this transition annually, little is known about their specific needs and risks at departure. To better identify needs and risks, we evaluated the discharge data of 640 youth served in a residential group care setting by addressing the following questions: (a) to what settings do youth depart following a stay in residential group care, (b) what are the demographic, family, educational, behavioral, and departure characteristics of youth at departure, and (c) do these characteristics differ for youth departing to different levels of restrictiveness? Results indicate significant differences on youth characteristics based on levels of restrictiveness at departure placement. As one might expect, youth departing to more restrictive placements presented a broad host of challenges across domains, while those departing to less restrictive settings demonstrated fewer needs and departed with greater educational and behavioral gains. Results provide support for the development and planning of targeted aftercare programs designed to promote the short and long term functioning of youth served in out-of-home care.     

Brain death, religious freedom, and public policy: New Jersey's landmark legislative initiative

"Whole brain death" (neurological death) is well-established as a legal standard of death across the country. Recently, New Jersey became the first state to enact a statute recognizing a personal religious exemption (a conscience clause) protecting the rights of those who object to neurological death. The Act also mandates adoption through the regulatory process of uniform and up-to-date clinical criteria for determining neurological death.     

Quality care in residential placement for children and youth with developmental disabilities

There is a growing concern for quality care in residential placements outside of the natural family for children and youth with developmental disabilities. Ideally, children with developmental disabilities should remain with their natural parent or parents of parents with appropriate supports until the age when children typically leave home. In reality, parents of children and youth with development disabilities are not always able or willing to care for their children at home, and alternate residential placements must be found. This paper will discuss some of the issues surrounding the provision of quality care in out-of-home residential placements for children and youth with developmental disabilities.     

Children with ADHD in Residential Care

Little is known about the characteristics or functioning of children with ADHD in residential care as compared to their non-ADHD peers. This study evaluated data on 538 children with (n = 125) and without (n = 413) ADHD in residential care to determine demographic, mental health, behavioral, and treatment (i.e., medication use) characteristics. Results revealed that both groups presented elevated risks, however, scores for children with ADHD indicated even greater levels of need. Specifically, differences were found between the two groups on demographics (e.g., family reunification status, restrictiveness of prior out-of-home placements), behavior (e.g., attention problems, rule-breaking and aggressive behaviors) and medication status. Findings suggest there is a need for aftercare services to help support families as children transition from care, interventions to address behavior, and medication management through assessment and monitoring.