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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
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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%
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Three-Tiered Prevention Program
Primary Program: Behavior and Academic Support
& Enhancement (BASE)
Secondary Program: First Step to Success
Tertiary Program: Multisystemic Therapy (MST)
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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
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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
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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)
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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
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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
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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.
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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.
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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.
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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.
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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.
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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)
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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)
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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)
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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
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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
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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%)
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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%)
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Case Examples
Examples of treatment principles and intervention philosophy with case examples
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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
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Social Adjustment (CBCL)
60
7068
50
55
60
65
70
75
Internalizing Externalizing Total Problems
Mean
Sta
nd
ard
S
core
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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
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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
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Parental Stress (PSI)
65
8590 88
0102030405060708090
100110
Parent Distress Parent-ChildDysfunction
Difficult Child Total Score
Perc
en
tile
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Maternal Depression (BDI)
10.17
0
2
4
6
8
10
12
14
16
18
20
BDI Total Score
Mean
Score
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Family Functioning (FACES)
4.2 4 4.1
0
1
2
3
4
5
6
7
8
Cohesion Adaptability Type
Mean
S
core
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Where are we now?
MST: 30 students in 2002-2003 40 students anticipated in 2003-2004
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Contact Information
Tricia Monzon, MA, LMHP, CPADACMST [email protected]
The Child Guidance Center Lincoln, NE
Jacquelyn A. Buckley, PhD, NCSP Michael H. Epstein, EdD Project Coordinator Principal Investigator [email protected] [email protected]
Center for At-Risk Children's ServicesUniversity of Nebraska-Lincoln
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For additional information about MST program
development, dissemination, and training, visit:
www.mstservices.com