Multisystemic Therapy: A Scottish Perspective

Nicola Hornsby, Programme Manager MST FifeCarole Murphy, Programme Manager MST Edinburgh

5th November 2015

What is Multisystemic Therapy?

• Community based, family driven intervention to address antisocial and offending behaviour in 12-17 year olds

• Addresses risk factors across multiple systems and builds protective factors

• Interventions are goal-orientated, problem-focused, and evidence-based e.g. behaviour therapy, cognitive behavioural therapy, pragmatic family therapies or parent management training

What is Multisystemic Therapy?

• Short-term (3-5 months) but intensive intervention

• 24/7 on-call service• Weekly group supervision and consultation• Continuous quality improvement - individual,

team and service level

Why we chose Multisystemic Therapy?

• MST offered aspects not already offered by existing local services

• Meets key service priorities of reducing out of home placements

• Successful implementation and outcomes elsewhere in UK

• High levels of technical assistance for implementation• Robust evidence base• Cost effectiveness data

MST Research Evidence

1. RCT’s by programme developers in US e.g. Borduin (1999) - some criticisms Littell et al (2005)

2. Long term RCT follow up – e.g. Sawyer & Borduin, 2011, 22 yrs post MST 75% fewer violent arrests

3. Independent RCT’s in the US e.g. Timmons-Mitchell et al 2006

4. Independent RCT’s in Europe (e.g. Norway - Ogden & Hagen, 2006, Ogden and Halliday-Boykins (2004)

5. UK RCT (Butler, Baruch, Hickey, & Fonagy, 2011) Compared MST directly with the use of Youth Offending Service statutory interventions. In the last 6 months of the study only 8% in the MST group against 34% in the YOS group had one or more further non- violent convictions

Independent support for the utility of MST

• Blueprints EBP database rating of ‘Model Plus’ • Recognised by United Nations Office on Drugs

and Crime (2010)• Multimodal interventions, for example MST,

are recommended in NICE guidelines for antisocial behaviour and conduct disorder (2013)

Cost effectiveness: UK studies

• Every pound spent on MST produces a return of £1.77 (Social Research Unit)

• Costing report on implementation of NICE guidance indicates MST to be cost effective in the UK.

MSTScotland

• Year MST started: 2009 (2 teams), 2011 (1 further team), 2013 (2 further teams added)

• Fife, Glasgow and Edinburgh outcomes combined (5 teams):– 604 families (cases closed to

date)– 87% completed the intervention– 89% youth at home– 75% youth in school/working– 65% youth no further charges

Using MST as Part of a Multiagency Approach to Reduce Risk of CSE

• Young people do not always perceive themselves as exploited

• Working systemically is a powerful way to address multiple risk factors quickly

• Needs a “dual approach” alongside investigation and information sharing to pursue perpetrators prosecution

• If families are provided with adequate support to reduce family conflict, improve relationships and monitoring and supervision and increase involvement in school/decrease association with antisocial peers then risk of CSE is reduced

Typical Pattern of Referral Behaviours for 12- 14 Year Olds

• Going missing: police reports for missing episodes• Verbal aggression at home: can occur daily. Abusive towards

parents when questioned about coming home late and going to school. Breakdown in parent/child relationship has resulted in parents demanding that child be taken into care

• Alcohol use: hospital admissions x 2 as a result of alcohol use• Posting naked images online: reports has experienced

cyberbullying from school peers as a result• Coming Home Late: every night. Associating with an older

peer group in local park• Non School Attendance: frequent truancy including period

truancy

Top Clinical Concern: Going Missing“Pull and push” factors

Going Missing

Young person anxious about attending school: absconds to avoid school

No incentive to come home on time ( more rewarding to be out)

Mum does not know what to do to get her home. Mum has given up. Easier at home when child not in house – less conflict

No clear curfew : Mum negotiating with child about when she can stay out until

contacts her Mum, while missing, thus Mum does not reporting her missing or take other action

Hanging around with unknown peers on local park who have late/no curfews

Antisocial influence contact her by text/online to encourage her out

It’s exciting to stay out

has money every day to go out from Mum

wants to make friends

School Holidays

Example Interventions DRIVER INTERVENTION

1.Mum does not know what to do to get young person home

Safety plan: included supervision and monitoring steps, 4W’s, check in’s. Identify additional family/friends support for Mum.

2.Hanging around with unknown peers on local park who have late/no curfews

Peer work: obtaining contact details, encouraging pro-social relationships, getting to know peer group and parents, target “safe” houses,

3. Antisocial influences contact girl online to tempt her out

Educate Mum re supervision and monitoring on line. Restrict access and clear rules use. Submit IRD. Liaison with CPT and PPU

4. No incentive to come home on time (more rewarding to be out)

Increasing “pull” factors back home. Teach Mum communication & de-escalation skills. Positive discipline strategies. Plan shared time together. Identify barriers to improving family relationships

5. Anxious about attending school: absconds to avoid school

Identifying appropriate school placement and supporting back into education. Building links with support staff in Education. Supporting positive home/school links and communication

Continuous Review

• Risk factors and interventions are reviewed on a weekly basis in order to give the family the necessary level of support required to successfully implement interventions

• i.e. not a “one off plan” but weekly review and development of interventions in order to overcome barriers to success

Key messages from Practice• Introducing EBP’s into local service delivery can be

an effective way of meeting service priorities• BUT: • Delivering expected outcomes requires

organisational support and understanding of the programme

• Clearly identify where the programme sits within a continuum of intervention/an effective referral pathway is essential

• Local support networks are important. MSTUK Network Partnership, Scottish MST Consultant

References

• Blueprints for Healthy Youth Development: http://blueprintsprograms.com

• NICE guidelines CG158 (March 2013): Antisocial behaviour and conduct disorders in children and young people: recognition, intervention and management. http://pathways.nice.org.uk/pathways/antisocial-behaviour-and-conduct-disorders-in-children-and-young-people

• Antisocial behaviour and conduct disorders in children and young people: Costing Report – Implementing NICE guidance. http://www.nice.org.uk/guidance/cg158/resources/cg158-conduct-disorders-in-children-and-young-people-costing-report2

References

• United Nations Office on Drugs and Crime (2010): Compilation of Evidence-Based Family Skills Training Programmes. http://www.unodc.org/docs/youthnet/compilation/10-50018 Ebook.pdf

• Social Research Unit (2012b). Investing in Children: Youth Justice 1.1. Dartington: SRU.