Research to Practice: Multisystemic Therapy (MST) for Elementary School Students with

Behavior DisordersCenter for At-Risk Children’s Services University of Nebraska-Lincoln

Jacquelyn A. Buckley, PhD & Michael H. Epstein, EdD

The Child Guidance Center Tricia Monzon, MA

Mental Health Status of School ChildrenThree types of children in school settings

Exhibit intense problem behavior

Not at risk

At risk for problem behavior

1-7%

5-15%

80-90%

Three-Tiered Prevention Program

Primary Program: Behavior and Academic Support

& Enhancement (BASE)

Secondary Program: First Step to Success

Tertiary Program: Multisystemic Therapy (MST)

BASE

Primary Schoolwide Discipline Program

Ecological arrangements: traffic patterns, arrival and dismissal, student supervision Behavior: consistent expectations, continuum of disciplinary responses, Think Time, behavior intervention plans

Academic: focus on achieving outcomes, early identification, evidence-based academic skill support

First Step to SuccessSecondary Program (Grades K-1)

Contingencies for Learning Academic and Social Skills (CLASS)

Teaching and role-playing appropriate behavior

Continuous feedback with visual and verbal prompts

Whole class reinforcement for meeting goals

homeBase

Six weekly lessons: communication, cooperation, limit setting, problem solving, making friends, developing confidence

MST

Family- and home-based treatment that strives to change how youth function in their natural settings – home, school, and neighborhood.

Clinical trial of MST adapted for younger children

Social-ecological framework

Family preservation mode of service delivery

Tertiary Program (Grades K-3)

Who is eligible for MST?

School Referred (Principal as main contact) K-3rd grade student BD label Currently experiencing significant

behavior problems

Additional ways to qualify: Lack of success in 1st Step Program Fall screening of K-1 students

Educational Labels MH, TBI, Autism, significant Visual/Hearing impairment,

Dual labels of BD and any excluded label (e.g., BD/MH)

Service History/Psychiatric Concerns Currently in psychiatric crisis (e.g., suicidal) More than 50% of the time over the past 2 years in out-

of-home/ out-of-community placement or pattern of multiple

placements Youth whose primary referral concern is internalizing

behaviors (e.g., depression) Youth with a Bipolar diagnosis Youth in foster care placements that are not potentially

long-term

Exclusionary Criteria

Why MST?

Evidence-based intervention for antisocial and delinquent adolescents

Effective in reducing criminal activity, antisocial behavior, other behavior problems, and out-of-home placements

Increases in family cohesion, adaptability, and supportiveness (Henggeler et al, 1998)

Why MST? MST’s focus on families as the solution U.S. Surgeon General: Report on Mental

Health and Report on Youth Violence U.S. Department of Justice - OJJDP NIDA, Center for Substance Treatment

(CSAT) & Center for Substance Abuse Prevention (CSAP)

National Association of State Mental Health Program Directors (NASMHPD)

Washington State Institute of Public Policy “Blueprints for Violence Prevention”

Adapted from MST Services (www.mstservices.com)

MST Assumptions & Beliefs Children’s behavior is influenced by

their families, friends, and community (and vice versa)

Families are the key to success Families can live successfully without

formal, mandated services Change can occur quickly Therapists should be held accountable

for achieving outcomes Research can provide guidance (i.e.,

empirically supported treatments) Adapted from MST Services (www.mstservices.com)

How MST works Treatment Site

Provider

Caseloads

Length of Treatment

Typical MST “aftercare”

Therapist Availability

Quality Assurance

Home, school, neighborhood and community

Single therapist (as part of, and supported by a team)

4-6 families

4 to 6 months in most cases

No formal, mandated services in place

24 hr\7 day\wk team available

TAM,SAM, Phone consultation Adapted from MST Services (www.mstservices.com)

MST Adaptations for K-3 Project

Referrals from schools, not DJJ,DSS, CW

Ages 5-9 with ED or DSM-IV label; MST typically is implemented with youth ages 12-17

Less emphasis on peers as a targeted area of intervention

K-3 youth not at imminent risk of placement; may be a stronger focus on engagement of caregivers

Adapted from MST Services (www.mstservices.com)

MST Adaptations for K-3 Project

Ensure supervisor has adequate knowledge base regarding younger children and their families

5-day initial training adapted to address evidence base on early childhood risk and protective factors & interventions

Dr. Sonja Schoenwald of FSRC participates in weekly telephone consultation in addition to the MST consultant

Adapted from MST Services (www.mstservices.com)

MST Principles

Nine principles of MST intervention design and implementation

Treatment fidelity and adherence is measured with relation to these nine principles

Adapted from MST Services (www.mstservices.com)

MST Treatment Principles 1. Finding the Fit

The primary purpose of assessment is to understand the “fit” between the identified problems and their broader systemic context.

2. Positive & Strength FocusedTherapeutic contacts should emphasize the positive and should use systemic strengths as levers for change.

MST Treatment Principles3. Increasing Responsibility

Interventions should be designed to promote responsibility and decrease irresponsible behavior among family members.

4. Present-focused, Action-oriented & Well-definedInterventions should be present-focused and action-oriented, targeting specific and well-defined problems.

MST Treatment Principles5. Targeting Sequences

Interventions should target sequences of behavior within and between multiple systems that maintain identified problems.

6. Developmentally AppropriateInterventions should be developmentally appropriate and fit the developmental needs of the youth.

MST Treatment Principles7. Continuous Effort

Interventions should be designed to require daily or weekly effort by family members.

8. Evaluation and AccountabilityInterventions efficacy is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.

MST Treatment Principles

9. GeneralizationInterventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering care givers to address family members’ needs across multiple systemic contexts.

Intervention Strategies Use of research-based treatment options

Behavior Therapy including Parent Management Training (PMT)

Cognitive behavior therapy Pragmatic family therapies: Structural Family

Therapy and Strategic Family Therapy Pharmacological interventions (e.g., for ADHD)

For K-3 project only: Components of Parent-Child Interaction

Therapy (PCIT; Eyeberg) Components of The Incredible Years (Webster-

Stratton) Adapted from MST Services (www.mstservices.com)

Intervention Philosophy

Services are comprehensive, individualized, and address all identified drivers of the problem behaviors

Therapists are accountable for all outcomes Families and communities are central and

essential partners in MST treatment Barriers to services are removed (e.g., 24/7

availability of team; scheduling meeting times that are convenient to families)

Adapted from MST Services (www.mstservices.com)

Wait-List Control Group Design

Child Outcome Measures Social

Child Behavior Checklist (CBCL); Behavioral and Emotional Rating Scale

(BERS); Social Skills Rating System (SSRS)

AcademicWoodcock-Johnson Tests of Academic Achievement, Third Edition (WJ-III);

Woodcock Reading Mastery Test – Revised (WRMT-R); Dynamic Indicators of

Basic Early Literacy Skills (DIBELS); Comprehensive Test of Phonological

Processing (CTOPP); Academic engaged time (AET)

Family Outcome Measures Family Adaptability and Cohesion Scale – III (FACES-III); Parenting Stress

Index (PSI); Beck Depression Inventory (BDI-III)

Characteristics of Participating Schools

School

Total

Enrollment

% Free/Reduced

Lunch

% Minority

Status

% Student Mobility

1

433

26.1

10.9

14.5

2

574

69.9

55.3

30.8

3

443

39.3

13.4

16.2

4

424

80.7

48.4

41.8

5

499

39.0

13.4

19.4

6

418

56.0

16.4

27.4

7

427

53.9

20.4

27.9

Child and Family Characteristics 1st Year Cohort

Data collected on 30 students referred for MST Data presented is intake data only 12 month availability of program - outcome data still being collected

Child Demographics Gender

Males = 26 (87%)Females = 4 (13%)

GradeKindergarten = 4 (13%)

1st grade = 9 (30%) 2nd grade = 6 (20%) 3rd grade = 11 (36.7%)

Ethnicity Caucasian = 24 (80%)African American = 4

(13%)Hispanic/Latino = 1 (3%)Native American = 1 (3%)

School ServicesSpecial Education = 24

(80%)Title 1 = 3 (10%)

Lunch Status Regular = 12 (40%)Free/Reduced = 18 (60%)

Child Developmental Risk Factors Prenatal

Maternal Medical Problems = 15 (50%)Maternal Emotional Problems = 15 (50%)

NatalChild Medical Problems = 11 (37%)

Premature birth = 5 (17%)

Family Family History of Mental Illness = 12 (40%)Family History of Criminal Activity = 15

(50%)Family History of Substance Abuse = 11

(37%)Family History of Domestic Violence = 16

(53%)Adverse Family Composition = 24 (80%) (e.g., divorce, separation)

AbusePhysical = 7 (23%)

Sexual = 2 ( 7%)

Case Examples

Examples of treatment principles and intervention philosophy with case examples

Academic Achievement (WJ-III & WJ Reading Mastery)

96

100

96

85

90

95

100

105

110

Reading Mathematics Written Langauge

Mean

Sta

nd

ard

S

core

Social Adjustment (CBCL)

60

7068

50

55

60

65

70

75

Internalizing Externalizing Total Problems

Mean

Sta

nd

ard

S

core

Social Adjustment (SSRS)

83

122

85

0

20

40

60

80

100

120

140

Social Skills Problem Behaviors AcademicCompetence

Mean

Sta

nd

ard

S

core

Child Strengths (BERS)

6.8

7.8 7.6 8.18.6

0

2

4

6

8

10

Interpersonal Family Involvement Intrapersonal School Functioning Affective

Mean

Sta

nd

ard

S

core

Parental Stress (PSI)

65

8590 88

0102030405060708090

100110

Parent Distress Parent-ChildDysfunction

Difficult Child Total Score

Perc

en

tile

Maternal Depression (BDI)

10.17

0

2

4

6

8

10

12

14

16

18

20

BDI Total Score

Mean

Score

Family Functioning (FACES)

4.2 4 4.1

0

1

2

3

4

5

6

7

8

Cohesion Adaptability Type

Mean

S

core

Where are we now?

MST: 30 students in 2002-2003 40 students anticipated in 2003-2004

Contact Information

Tricia Monzon, MA, LMHP, CPADACMST Supervisortriciamonzon1@aol.com

The Child Guidance Center Lincoln, NE

Jacquelyn A. Buckley, PhD, NCSP Michael H. Epstein, EdD Project Coordinator Principal Investigator jbuckley2@unl.edu mepstein1@unl.edu

Center for At-Risk Children's ServicesUniversity of Nebraska-Lincoln

For additional information about MST program

development, dissemination, and training, visit:

www.mstservices.com