A randomized randomised controlled trial of Multisystemic Therapy and statutory therapeutic intervention for young offenders

Objective: (1) to evaluate whether Multisystemic Therapy (MST) is more effective in reducing youth offending and out-of-home placement in a large, ethnically diverse, urban UK sample than an equally comprehensive management protocol; and (2) to determine whether MST leads to broader improvements in youth sociality and in mediators believed to be responsible for change in MST. Method: 108 families were randomized to either MST (n=56) or the comprehensive and targeted usual services delivered by youth offending teams (YOT, n=52). Results: although both MST and YOT interventions appeared highly successful in reducing offending, the MST model of service-delivery reduced significantly further the likelihood of non-violent offending during an 18-month follow-up period. Consistent with offending data, the results of youth-reported delinquency and parental reports of aggressive and delinquent behaviors show significantly greater reductions from pre-treatment to post-treatment levels in the MST group. Conclusions: The superiority of the MST condition in reducing offending and antisocial behavior suggests that MST adds value to current UK statutory evidence-based youth services. The provision of MST cannot supplant existing services but is best used to facilitate the appropriate and cost-effective organization of statutory services for young persons and their families. Introduction Juvenile delinquents are poorly served by current statutory systems, and demand for effective therapies is acute. Serious and repeated antisocial behavior during childhood and adolescence is relatively common and can have significant and costly long-term consequences for individuals, their families and society. Of juveniles with diagnosable conduct disorder (CD), over three-fifths have severe problems: 29% have pervasive CD with an average of 8eight symptoms including aggression; a further 29% endorse on average six symptoms including theft and other propertyoriented offenses (but not physical violence); and 3% appear to be primarily aggressive. Most serious youth antisocial behavior is committed by a very small group of persistent offenders. Antisocial behavior in childhood generally progresses through adolescence and becomes antisocial personality disorder (ASPD) in adult life. Multisystemic Therapy (MST) is an intensive family-and-home-based intervention for young people with serious antisocial behavior. It aims to prevent re-offending and out-of-home placements. MST was developed in response to research on the multi-determined nature of antisocial behavior, and adopts a social-ecological approach to intervention. MST improves behavior by intervening in the many systems of which juveniles are part. A large body of evidence supports the efficacy of MST in reducing recidivism and custodial sentences amongst serious juvenile offenders. MST has been widely applied in the US and in other countries including Canada, Holland, Norway, Sweden, Denmark, New Zealand, and, most recently, the UK. A number of good-quality randomized controlled trials (RCT) suggested that MST was the most effective treatment for reducing adolescents’ recidivism and improving individual and family pathology. However, more recent reviews have been less positive. Studies in Canada and Sweden found that MST failed to reduce antisocial behavior more than in usual service conditions did. In the first RCT of MST conducted in the US without direct involvement of the treatment developers, re-offending rates in the MST group remained high (even though the intervention significantly reduced re-offending compared to treatment as usual [MST 66.7% vs. TAU 86.7%]). For trials of MST involving the developers, effect sizes associated with efficacy are substantially higher (.81) than effectiveness in studies conducted without their close involvement (.27). This may be due to reduced treatment adherence, the quality of TAU in the US, or the options for legal dispositions when dealing with young offenders. Internationally, the replicability of the US findings from the US has been mixed. This suggests that MST’s relative success may not be due to the rigorous application of MST principles but rather to the poor quality of the standard US services for managing CD. Thus, for MST to be considered valuable, its superiority should be demonstrated outside the US in legal jurisdictions and regions where: (a) the evidence-base (EB) for TAU (associated with socialized healthcare systems) is stronger than for TAUs identified in earlier clinical trials initiated by the developers of MST (e.g. individual psychotherapy); (b) the motivation of therapists delivering MST is lower than the motivation of those who were involved in MST’s development; and (c) standards with regard to sentencing policy do not result in a comparison with toxic alternatives such as custodial sentences. In the UK, a relatively generous supportive framework is provided by usual services. This offers a better testing ground for the value added by MST. In England and Wales, the Crime and Disorders Act (1998) established a new youth-justice system and Youth Offending Teams (YOTs), the principal aim of which is to prevent offending by young people. Under this framework, EB interventions address the personal, family, social, educational and health factors that put a young person at risk of offending, and build on protective factors to ameliorate their difficulties. As in MST, interventions target well-known risks (e.g. non-attendance at school, poor anger-management and poor problem-solving skills). Parents’ responsibilities are reinforced although treatment is not focused on parenting. An allocated YOT social worker works to encourage young persons to develop responsibility for their behavior and consideration for the victims of their crimes. The present study is the first RCT of MST that contrasts it with the current protocols for youth offenders in the UK. The involvement of MST developers was limited to launching the service and ensuring fidelity to the model; the evaluation was independently conducted. Finally, unlike Scandinavian studies, the compatibility of the US and UK legal systems permits primary and secondary outcomes to be compared with those from the early efficacy studies conducted in the US. The English system provides primary outcomes, objective offending data and custodial rates. These have not been available in other European trials because antisocial behavior in these countries is dealt with by the child welfare system. Hence, it is difficult to compare these previous European MST trials to US studies in the US and to generalize to the UK. The study aims to: (1) evaluate in a large, ethnically diverse, urban UK sample whether MST is more effective in reducing youth offending and out-of-home placement than a similarly comprehensive management protocol not based on MST principles; and (2) determine whether MST leads to broader improvements in youth sociality, family function and potential mediators of change (such as parenting skills, parent-adolescent communication, and disassociation from deviant peers). Method This study was approved by the local Research Ethics (IRB) Committee. Setting and Inclusion Criteria From November 2003 to December 2009, the trial used consecutive referrals from two local youth offending services in North London. Young people were included in the study if they were: (i) between 13 and 17 years old; (ii) living in the home of and being brought up by a parent or principal carer; and (iii) on a court referral order for treatment, a supervision order of at least three months duration, or, following imprisonment, on license in the community for at least 6 months. They were excluded if they: (i) were a sex offender; (ii) presented only with substance misuse; (iii) were diagnosed with a psychotic illness; or (iv) posed a risk to trial personnel. They were also excluded if: (v) there was incompatible agency involvement (e.g. ongoing care proceedings). Participants Figure 1 shows the flow of participants through the trial. Four-hundred-and-seventy-eight young people were referred to the treatment team during the study period, of whom 370 were excluded because they could not be contacted, refused to consent to assessment, did not meet one or more inclusion criteria, or met one of the exclusion criteria. Families declined to participate mostly because the parent or carer felt there were no recent, current or anticipated difficulties with a young person’s behavior. This left 108 to be randomized into MST (n=56) or YOT (n=52). There was no difference in the distribution of completer categories across the groups (χ 2 =1.87, df=2, p=.18). Table 1 shows the demographic and clinical details of this sample. The majority was male (about equal numbers Caucasian and Black) and had an average of more than 2two offenses at intake (range 0–6). Over half the convictions included violent offenses and 41% had only non-violent convictions. Across the sample, the age of contact with youth offender services (14.9 years) and number of convictions (2.03) were representative of the population of young offenders in the London area that the sample was drawn from. Only a small minority was living with two parents; over twothirds lived with their mothers but not their fathers, and less than 10% with their fathers but not their mothers. Only onethird was in mainstream education. Thirty-one per cent of the parents had left school with no academic qualifications; 40% had no vocational qualifications; and 54% were without income. In sum, almost all subjects lived in socio-economically disadvantaged families. Randomization Following acceptance of the referral, a standard initial letter in the family’s first language was sent to parents (and separately to young persons 16 or older), informing them about the trial, the standard explanatory visit and a standard consenting procedure. After 1-2 weeks, a member of the MST team visited th