Multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour (START): 5-year follow-up of a pragmatic, randomised, controlled, superiority trial.

BACKGROUND: Multisystemic therapy is a manualised treatment programme for young people aged 11-17 years who exhibit antisocial behaviour. To our knowledge, the Systemic Therapy for At Risk Teens (START) trial is the first large-scale randomised controlled trial of multisystemic therapy in the UK. Previous findings reported to 18 months after baseline (START-I study) did not indicate superiority of multisystemic therapy compared with management as usual. Here, we report outcomes of the trial to 60 months (START-II study). METHODS: In this pragmatic, randomised, controlled, superiority trial, young people (aged 11-17 years) with moderate-to-severe antisocial behaviour were recruited from social services, youth offending teams, schools, child and adolescent mental health services, and voluntary services across England, UK. Participants were eligible if they had at least three severity criteria indicating past difficulties across several settings and one of five general inclusion criteria for antisocial behaviour. Eligible families were randomly assigned (1:1), using stochastic minimisation and stratifying for treatment centre, sex, age at enrolment, and age at onset of antisocial behaviour, to management as usual or 3-5 months of multisystemic therapy followed by management as usual. Research assistants and investigators were masked to treatment allocation; the participants could not be masked. For this extension study, the primary outcome was the proportion of participants with offences with convictions in each group at 60 months after randomisation. This study is registered with ISRCTN, ISRCTN77132214, and is closed to accrual. FINDINGS: Between Feb 4, 2010, and Sept 1, 2012, 1076 young people and families were assessed for eligibility and 684 were randomly assigned to management as usual (n=342) or multisystemic therapy (n=342). By 60 months' of follow-up, 188 (55%) of 342 people in the multisystemic therapy group had at least one offence with a criminal conviction, compared with 180 (53%) of 341 in the management-as-usual group (odds ratio 1·13, 95% CI 0·82-1·56; p=0·44). INTERPRETATION: The results of the 5-year follow-up show no evidence of longer-term superiority for multisystemic therapy compared with management as usual. FUNDING: National Institute for Health Research Health Services and Delivery Research programme.

General and specific factors of working alliance in parent training: A bifactor exploratory structural equation modelling approach.

The Working Alliance Inventory Short form (WAI-S) comprises 12 items that measure 3 subdomains (goal, task, and bond). In the present study, we evaluated the factor structure of WAI-S in a parent management training (PMT) context, by investigating a series of different factor models, including standard confirmatory factor analyses (CFA) models and more recent alternatives, like the exploratory structural equation model (ESEM), the bifactor-CFA, and the bifactor exploratory structural equation model (B-ESEM). The study sample consisted of 259 Norwegian parents receiving PMT - the Oregon model (PMTO). Alliance was rated by parents of children with emerging or present conduct problems after the first therapy session. Results showed that the B-ESEM model provided best model fit to the data. Estimated sources of variance and omega reliabilities supported a strong general alliance factor, but revealed poor quality of the specific factors. Overall, the present study implies that specific factors of working alliance should be interpreted with caution; rather one should rely on a general working alliance construct. Clinical or methodological significance of this article: Findings suggest that working alliance, as measured by WAI-S in a PMT context, is best reflected by a general construct that also take into account multidimensionality. However, only the general factors provide acceptable reliability. Consequently, practitioners should use the specific factors with caution. The indicators of the specific factors should be improved.

Implementation and evaluation of a parenting program to prevent child maltreatment in Suriname.

The prevention of child maltreatment has become a global health concern because child maltreatment is a violation of children's rights. Across the world, a variety of parenting programs have been developed to address this problem. However, no such parenting program currently exists in Suriname. This pilot study aimed to implement Lobi Mi Pikin (LMP) parenting program in Suriname and to evaluate its effects on corporal punishment (CP) and child behavioral problems. Parents-caregivers (N = 70) of children (ages 3-12 years) with externalizing behavioral problems participated in a protocoled parenting program. The child's behavioral problems and the parenting style of the parent-caregiver were assessed using the Strengths and Difficulties Questionnaire and the Parental Behavior Scale, pretreatment and posttreatment. Five-week follow-up measures revealed significant positive effects of LMP on all outcome measures. Follow-up comparisons demonstrated (a) a large reduction of total child difficulties and conduct problems, (b) a moderate reduction of hyperactivity and emotional problems, (c) a moderate to large increase in the self-reported positive behavior of the parent, and (d) a small decrease in the use of CP. This study provides preliminary evidence that LMP may be an effective model of parent training in Suriname. Moreover, it can help guide efforts to reduce the use of CP and encourage positive parenting, thereby preventing child maltreatment. (PsycINFO Database Record

Racial/Ethnic Disproportionality in Psychiatric Diagnoses and Treatment in a Sample of Serious Juvenile Offenders.

Psychiatric disorder prevalence has been shown demonstrably higher among justice-involved adolescents than youth in the general population. Yet, among arrested juveniles, little is known regarding racial/ethnic differences in disorder prevalence, the role of trauma exposure in the diagnosis of behavioral disorders, or subsequent psychiatric treatment provided to adolescents with such diagnoses. The current study examines racial/ethnic disparity in psychiatric diagnoses and treatment of behavioral disorders associated with delinquency, controlling for traumatic experiences, behavioral indicators, and prior offending among serious juvenile offenders. Logistic regression is employed to explore the racial/ethnic disproportionality in behavioral disorder diagnoses and psychiatric treatment provision among 8763 males (57.7 % Black, 11.8 % Hispanic) and 1,347 females (53.7 % Black, 7.6 % Hispanic) admitted to long-term juvenile justice residential placements in Florida. The results indicate Black males are 40 % more likely, and Black females 54 % more likely to be diagnosed with conduct disorder than Whites, even upon considerations of trauma, behavioral indicators, and criminal offending. Black and Hispanic males are approximately 40 % less likely to be diagnosed with ADHD than White males, with no racial/ethnic differences for females. Importantly, Black males are 32 % less likely to receive psychiatric treatment than White males, with no differences between White and Hispanic males, or any female subgroups. Traumatic exposures increased the odds of oppositional defiant disorder and ADHD, but not conduct disorder for males, though adverse childhood experiences were unrelated to behavioral disorder diagnoses among females.

Multi-dimensional Treatment Foster Care in England: differential effects by level of initial antisocial behaviour.

Multi-dimensional Treatment Foster Care (MTFC), recently renamed Treatment Foster Care Oregon for Adolescents (TFCO-A) is an internationally recognised intervention for troubled young people in public care. This paper seeks to explain conflicting results with MTFC by testing the hypotheses that it benefits antisocial young people more than others and does so through its effects on their behaviour. Hard-to-manage young people in English foster or residential homes were assessed at entry to a randomised and case-controlled trial of MTFC (n = 88) and usual care (TAU) (n = 83). Primary outcome was the Children's Global Assessment Scale (CGAS) at 12 months analysed according to high (n = 112) or low (n = 59) baseline level of antisocial behaviour on the Health of the Nation Outcome Scales for Children and Adolescents. After adjusting for covariates, there was no overall treatment effect on CGAS. However, the High Antisocial Group receiving MTFC gained more on the CGAS than the Low group (mean improvement 9.36 points vs. 5.33 points). This difference remained significant (p < 0.05) after adjusting for propensity and covariates and was statistically explained by the reduced antisocial behaviour ratings in MTFC. These analyses support the use of MTFC for youth in public care but only for those with higher levels of antisocial behaviour. Further work is needed on whether such benefits persist, and on possible negative effects of this treatment for those with low antisocial behaviour.Trial Registry Name: ISRCTNRegistry identification number: ISRCTN 68038570Registry URL: www.isrctn.com.

[School well-being of students with and without special educational needs--a comparison of students in inclusive and regular classes]. / Schulisches Wohlbefinden von SchülerInnen mit und ohne sonderpädagogischen Förderbedarf--Integrations- und Regelklassen im Vergleich.

OBJECTIVE: The present study examines the academic well-being of students with and without special educational needs (SEN) in inclusive classes compared to students from regular classes in which no child with SEN is taught. In addition, the relationships between the school well-being and emotional problems, conduct problems, hyperactivity/inattention, peer relationship problems and prosocial behavior are analyzed. METHOD: A total of 1115 students from the 4th and 7th grade (37 % 4th graders, 63 % 7th graders) participated in the survey, 126 of whom had been diagnosed as having SEN. The subscale Well-Being at School taken from the FEESS 3­4 (Rauer & Schuck, 2004) and the SDQ (Goodman, 1997) were used for measurement. RESULTS: Results indicate high reliabilities for the subscale Well-Being in School for students both with and without SEN for both grades 4 and 7. Furthermore, it could be shown that the variance explained for school well-being can be connected to elements on the students' individual level as well as on the class-specific level. Significant predictors of school well-being were sex, behavioral difficulties and strengths as well as the school grade. The SEN status (no SEN vs. SEN) and the class setting (regular vs. inclusive class) did not influence the school well-being significantly.

Impact of early intervention on psychopathology, crime, and well-being at age 25.

OBJECTIVE: This randomized controlled trial tested the efficacy of early intervention to prevent adult psychopathology and improve well-being in early-starting conduct-problem children. METHOD: Kindergarteners (N=9,594) in three cohorts (1991-1993) at 55 schools in four communities were screened for conduct problems, yielding 979 early starters. A total of 891 (91%) consented (51% African American, 47% European American; 69% boys). Children were randomly assigned by school cluster to a 10-year intervention or control. The intervention goal was to develop social competencies in children that would carry them throughout life, through social skills training, parent behavior-management training with home visiting, peer coaching, reading tutoring, and classroom social-emotional curricula. Manualization and supervision ensured program fidelity. Ninety-eight percent participated during grade 1, and 80% continued through grade 10. At age 25, arrest records were reviewed (N=817, 92%), and condition-blinded adults psychiatrically interviewed participants (N=702; 81% of living participants) and a peer (N=535) knowledgeable about the participant. RESULTS: Intent-to-treat logistic regression analyses indicated that 69% of participants in the control arm displayed at least one externalizing, internalizing, or substance abuse psychiatric problem (based on self- or peer interview) at age 25, in contrast with 59% of those assigned to intervention (odds ratio=0.59, CI=0.43-0.81; number needed to treat=8). This pattern also held for self-interviews, peer interviews, scores using an "and" rule for self- and peer reports, and separate tests for externalizing problems, internalizing problems, and substance abuse problems, as well as for each of three cohorts, four sites, male participants, female participants, African Americans, European Americans, moderate-risk, and high-risk subgroups. Intervention participants also received lower severity-weighted violent (standardized estimate=-0.37) and drug (standardized estimate=-0.43) crime conviction scores, lower risky sexual behavior scores (standardized estimate=-0.24), and higher well-being scores (standardized estimate=0.19). CONCLUSIONS: This study provides evidence for the efficacy of early intervention in preventing adult psychopathology among high-risk early-starting conduct-problem children.

Therapist self-report of evidence-based practices in usual care for adolescent behavior problems: factor and construct validity.

This study introduces a therapist-report measure of evidence-based practices for adolescent conduct and substance use problems. The Inventory of Therapy Techniques-Adolescent Behavior Problems (ITT-ABP) is a post-session measure of 27 techniques representing four approaches: cognitive-behavioral therapy (CBT), family therapy (FT), motivational interviewing (MI), and drug counseling (DC). A total of 822 protocols were collected from 32 therapists treating 71 adolescents in six usual care sites. Factor analyses identified three clinically coherent scales with strong internal consistency across the full sample: FT (8 items; α = .79), MI/CBT (8 items; α = .87), and DC (9 items, α = .90). The scales discriminated between therapists working in a family-oriented site versus other sites and showed moderate convergent validity with therapist reports of allegiance and skill in each approach. The ITT-ABP holds promise as a cost-efficient quality assurance tool for supporting high-fidelity delivery of evidence-based practices in usual care.

Head start participation and school readiness: evidence from the Early Childhood Longitudinal Study-Birth Cohort.

Using data from the Early Childhood Longitudinal Study-Birth Cohort (n ≈ 6,950), a nationally representative sample of children born in 2001, we examined school readiness (academic skills and socioemotional well-being) at kindergarten entry for children who attended Head Start compared with those who experienced other types of child care (prekindergarten, other center-based care, other nonparental care, or parental care). Using propensity score matching methods and ordinary least squares regressions with rich controls, we found that Head Start participants had higher early reading and math scores than children in other nonparental care or parental care but also higher levels of conduct problems than those in parental care. Head Start participants had lower early reading scores compared with children in prekindergarten and had no differences in any outcomes compared with children in other center-based care. Head Start benefits were more pronounced for children who had low initial cognitive ability or parents with low levels of education or who attended Head Start for more than 20 hr per week.

Counting down: HIV prison-based peer education programs and their connection to reduced disciplinary infractions.

Involvement in prosocial prison activities can ameliorate rule-breaking conduct and assist in the reinforcement of conventional behavior. Extant research shows a connection between participation in traditional educational/vocational programs and reduced prison infractions. However, studies that examine a correlation between less traditional prison programs and better institutional conduct are lacking. This study analyzed rates of disciplinary infractions among 49 female prisoners that worked in two HIV prison-based peer programs (AIDS, Counseling, and Education [ACE] and CARE [Counseling, AIDS, Resource, and Education]) as peer educators during their incarceration. These women were unlikely to jeopardize their position by engaging in unlawful or deviant behaviors. Results showed that working in programs like ACE/CARE prevented periods of maladjustment and subsequent disciplinary infractions during incarceration.

Assessing fidelity to evidence-based practices in usual care: the example of family therapy for adolescent behavior problems.

This study describes a multimethod evaluation of treatment fidelity to the family therapy (FT) approach demonstrated by front-line therapists in a community behavioral health clinic that utilized FT as its routine standard of care. Study cases (N=50) were adolescents with conduct and/or substance use problems randomly assigned to routine family therapy (RFT) or to a treatment-as-usual clinic not aligned with the FT approach (TAU). Observational analyses showed that RFT therapists consistently achieved a level of adherence to core FT techniques comparable to the adherence benchmark established during an efficacy trial of a research-based FT. Analyses of therapist-report measures found that compared to TAU, RFT demonstrated strong adherence to FT and differentiation from three other evidence-based practices: cognitive-behavioral therapy, motivational interviewing, and drug counseling. Implications for rigorous fidelity assessments of evidence-based practices in usual care settings are discussed.

Social inclusion and people with intellectual disability and challenging behaviour: a systematic review.

BACKGROUND: Social inclusion is central to disability policies internationally. The high risk of social exclusion for people with intellectual disability is compounded for those with challenging behaviour. METHOD: A systematic literature review examined how social inclusion of people with intellectual disability and challenging behaviour has been researched and operationalised in the empirical literature, and aimed to determine what evidence exists about the extent of social inclusion by people with intellectual disability and challenging behaviour. RESULTS: A thematic analysis of the 14 papers identified that social inclusion has been poorly defined and measured, and that the little research that has occurred in respect of people with challenging behaviour has demonstrated their potential to be socially included. CONCLUSIONS: Clearer conceptualisation of inclusion, and greater understanding of practices that support social inclusion and system level mechanisms, which ensure goals around inclusion gain prominence in funding and support plans, may address the neglect of this critical quality-of-life domain for people with challenging behaviour.

Medical marijuana use among adolescents in substance abuse treatment.

OBJECTIVE: To assess the prevalence and frequency of medical marijuana diversion and use among adolescents in substance abuse treatment and to identify factors related to their medical marijuana use. METHOD: This study calculated the prevalence and frequency of diverted medical marijuana use among adolescents (n = 164), ages 14-18 years (mean age = 16.09, SD = 1.12), in substance abuse treatment in the Denver metropolitan area. Bivariate and multivariate analyses were completed to determine factors related to adolescents' use of medical marijuana. RESULTS: Approximately 74% of the adolescents had used someone else's medical marijuana, and they reported using diverted medical marijuana a median of 50 times. After adjusting for gender and race/ethnicity, adolescents who used medical marijuana had an earlier age of regular marijuana use, more marijuana abuse and dependence symptoms, and more conduct disorder symptoms compared with those who did not use medical marijuana. CONCLUSIONS: Medical marijuana use among adolescent patients in substance abuse treatment is very common, implying substantial diversion from registered users. These results support the need for policy changes that protect against diversion of medical marijuana and reduce adolescent access to diverted medical marijuana. Future studies should examine patterns of medical marijuana diversion and use in general population adolescents.

Internet-based parent management training: a randomized controlled study.

OBJECTIVE: The current study evaluated the efficacy of an Internet-based parent-training program for children with conduct problems. Dose-response ratio and costs for the program were also considered. METHOD: Parents of 104 children (aged 3-12 years) were randomly allocated to either parent training or a waitlist control condition. Diagnostic assessment was conducted at baseline and parent ratings of child externalizing behaviors and parent strategies were completed before and after treatment and at 6-month follow-up. RESULTS: At post-treatment assessment, children whose parent(s) had received the intervention showed a greater reduction in conduct problems compared to the waitlist children. Between group intent-to-treat effect sizes (Cohen's d) on the Eyberg Intensity and Problem scales were .42 and .72, respectively (study completers .66 and 1.08). In addition, parents in the intervention group reported less use of harsh and inconsistent discipline after the treatment, as well as more positive praise. Effects on behavior problems were maintained at 6-month follow-up. CONCLUSIONS: The results support the efficacy of parent training, administered through Internet, with outcomes comparable to many of the group-based parent training programs. The efficacy, low cost, and higher accessibility make this intervention a fitting part in a stepped-care model.

Coping with challenging behaviours of children with autism: effectiveness of brief training workshop for frontline staff in special education settings.

BACKGROUND: The present study examined the effectiveness of three staff training elements: psychoeducation (PE) on autism, introduction of functional behavioural analysis (FBA) and emotional management (EM), on the reaction of challenging behaviours for frontline staff towards children with autism in Hong Kong special education settings. METHODS: A sample of 311 frontline staff in educational settings was recruited to one of the three conditions: control, PE-FBA and PE-FBA-EM groups. A total of 175 participants completed all three sets of questionnaires during pre-training, immediate post-training and 1-month follow-up. RESULTS: Findings showed that the one-session staff training workshop increased staff knowledge of autism and perceived efficacy but decrease helping behavioural intention. CONCLUSIONS: In spite of the limited effectiveness of a one-session staff training workshop, continued staff training is still necessary for the improvement of service quality. Further exploration on how to change emotion response of staff is important.

[Initiation of ecstasy use in Québec senior high school adolescents: distal and proximal predictors]. / Initiation de la consommation d'ecstasy chez les adolescents québécois à la fin du secondaire: prédicteurs distaux et proximaux.

OBJECTIVE: To identify distal and proximal predictors of ecstasy use initiation during adolescence. METHOD: The sample included 2162 adolescents from Québec disadvantaged community high schools, with an annual follow-up for 5 years. Path analysis was used to predict ecstasy use initiation in secondary 5 (aged 16 to 17 years) from predictors in secondary 1 and 2 (aged 12 to 14 years) and in secondary 4 (aged 15 to 16 years). RESULTS: Secondary 5 adolescents initiating ecstasy use showed a higher risk on multiple factors, compared with nonusers. Initiation was mainly predicted by proximal risk factors related to individual use as well as peer use and deviance. Nevertheless, many proximal factors developed consistently with their corresponding distal factor (indirect link). Marijuana use was the strongest predictor of ecstasy use initiation. All things being equal, relative risk was 2.04 times higher in adolescents having used marijuana in the past year (secondary 4). CONCLUSIONS: Ecstasy use initiation in secondary 5 seems to be globally related to an externalized, rather than internalized, profile. This ecstasy use was strongly associated with other substance use and likely shares many risk factors with other substance use, specifically marijuana use.

[Multisystemic Therapy (MST) for adolescents with severe conduct disorders in German-speaking Switzerland - implementation and first results]. / Multisystemische Therapie (MST) für Jugendliche mit schweren Störungen des Sozialverhaltens.

OBJECTIVE: To determine the extent to which MST can be applied in German-speaking Switzerland, and the extent to which respectable international treatment outcomes can be replicated. METHOD: A sample of 70 adolescents was treated for an average of 155 days. Of these adolescents, 60 (85.5 %) remained in the study until the conclusion of treatment. The results of the parent version of the Strengths and Difficulties Questionnaire (SDQ) are available for 38 (63.3 %) of the completers. For 52 patients (86.7 %), the therapist ratings for Values for Clinical Global Impression (CGI) and for Global Assessment of Functioning (GAF) are available. RESULTS: The overall problem score of the parent version of the SDQ was reduced from 20 at the beginning of treatment to 14.6 at the conclusion of treatment. The overall score of the GAF improved from 55.4 to 70.3, and the CGI improved from 3.6 to 2.7 points. These results are statistically highly significant. The 6-month follow-up interview revealed treatment success rates of 91 % for «adolescent remains in his family of origin,¼ 94 % for «adolescent remains in school or vocational training,¼ and 91 % for «adolescent does not commit chargeable offences.¼ The 18-month follow-up interviews show success rates of 80 %, 86 %, and 86 %, respectively. CONCLUSIONS: Multisystemic Therapy is a complex treatment program that is clearly applicable in the cultural environment of Switzerland. Respectable international results were replicated in this sample.

[Multisystemic Therapy (MST) for youths with severe conduct disorders - economic evaluation of the implementation in a German-speaking environment]. / Multisystemische Therapie (MST) für Jugendliche mit schweren Störungen des Sozialverhaltens.

OBJECTIVE: Multisystemic Therapy (MST) was adapted for implementation in a German-speaking environment. The study evaluates the possible economic effects of MST. METHOD: Professionals who recommended MST for youths with severe conduct disorders were asked to evaluate the probability of other forms of interventions if MST had not been used. We investigated the costs of those other forms of treatment and compared them to the costs that had actually been incurred with MST. RESULTS: Implementation of MST in a German-speaking environment showed a significant potential of cost savings compared to other intervention methods. The costs of MST per case were between 40 % and 64 % lower than these of standard interventions. CONCLUSIONS: MST is not only an effective, but also a cost-efficient form of evidence-based treatment for youths with severe conduct disorders.