Implementation of MST in Norway Iceland June 2008 Bernadette Christensen Clinical Director of the Youth Department Anne Cathrine Strütt MST Consultant.

Implementation of MST in NorwayIceland June 2008

Bernadette Christensen Clinical Director of the Youth Department Anne Cathrine StrüttMST Consultant

The Norwegian Center for Child Behavioral Development

Why MST In Norway?

• Much media attention to the deficiencies within the child welfare systems and the lack of professional personnel within some of the institutions

• The fact that kids were being institutionalized, for longer period of time, far away from their homes and returning not having been helped (no changes in their original environment and little changes in their own behavior)

Why MST In Norway? (continued)

• Great budgetary deficits because of the amount of out-of-home placements

• The child and youth psychiatric clinics had little or no treatment services for adolescents with serious behavior problems

• By law - family based help and support should be tried before the children are placed out of home

Implementation Process in Norway

• 1997: Lack of services and competence in Child Welfare and Child Psychiatric Services: An international expert conference hosted by the Norwegian Research Council

• 1998: An expert panel report recommending the implementation and controlled evaluation of selected evidence based programs

• 1999: Towards ”evidence based practice”: nationwide implementation of PMTO and MST

• 2000: PMTO/MST clinical outcome studies – new standards for clinical outcome research

• 2003: The Norwegian Center for Child Behavioral Development (Atferdssenteret – University of Oslo Affiliate

Facilitators at the National Level• A genuine interest and commitment at the political and administrative level –

consistent funding from The Ministry of Child..and the Ministry of Social and Health

• Determination and support to establish a national implementation and research center• National implementation teams for children and youth• Research group

• Plans for program implementation in all of Norway - Establishing comprehensive training- and maintenance programs for therapists and supervisors

• Creating professional networks for collaboration and quality control

• Conducting research on clinical outcomes, the implementation process and on the development of serious behavior problems in children and youth

• Positive feedback from families and media

MST

Goals &Guidelines

Site assessments

MonthlyReview

ProgramImplementation

Review

Weekly clinicalSupervision

Weekly clinical consultation

TAM SAM

5 day MST training

IndividualDevelopment

Plans

THE MST MODEL

Treatment Adherence

Quarterly boosters

Implementation of the MST treatment model in Norway has required a persistent multi-level effort:

• Legal adaptation• Organizational factors – nationwide and regionally• Attitudes towards treatment and therapist role• Development, consolidation and maintenance of an MST

organization in Norway• Development of the Norwegian adaptation of the Quality

Assurance System

18.04.23 © Norsk senter for studier av problematferd og innovativ praksis

MST in Norway

• 22 MST-teams are established across all regions of Norway as part of the National Child Welfare Services

• All MST training, consultation and boosters are done by 7 Norwegian Consultants in Collaboration with MST Services

• 3500 families and youth have received MST

• Clinical Outcome Study MST (100 families)

• Clinical Outcome Study with Contingency Management and Treatment Adherence

Transportability Challenges

• The Transportability of the clinical method

• Conflicting Ideologies

• Support of evidence based methods and willingness to work in a structured and systematic way

Continuous Challenges

• Treatment Fidelity• Sustainability• Referrals

– getting the right referrals

- caseload

Characteristics of the Norwegian MST clinical outcome study

• The first controlled evaluation study (RCT) of MST outside North America and in a non-english speaking country

• One of the first trials not involving the developers of MST • The trial was conducted by independent investigators who did

not participate in the training and supervision of MST therapists nor in the actual treatment of families

• One of the first MST studies examining site differences in treatment effects

• Implemented as ’real world’ treatment in a country without a juvenile court system (Child Welfare Services only).

Conclusions of the Norwegian MST EvaluationConclusions of the Norwegian MST Evaluation

• The Norwegian findings support the effectiveness of MST relative to the services usually available for youths with serious behaviour problems at three out of four sites

• MST prevented placement out of home to a greater extent than regular services

• MST was associated with decreased internalising and externalising problem behavior in youths

• A marginally greater caregiver satisfaction with treatment relative to RS was reported by the MST families at post assessment

• Differential MST treatment effects across sites at post treatment and at follow up, may be due to variability in the quality of treatment implementation.

Future Plans for the Department of Youth

• Training MST consultants in collaboration with MST Services

• Continuous Development of MST training documents in Norwegian

• More MST teams where needed• Participation in research studies on Drug abuse

CM (Contingency Management)• More evidence based programs for youth –

FFT and MTFC

Norwegian Progaram Monitoring Results

MST in Norway

• 1999: The first 4 teams• 2007: 22 teams - nation-wide• 1997-2007: 3500 families in MST

Organization

Supervisor TherapistYouth/family

TAM-R

ManualManual

Consultant

Manual

Program data and treatment

results

Manual

Adherencemeasure

Adherencemeasure

Organization

Supervisor TherapistYouth/family

TAM-R

ManualManual

Consultant

Manual

Program data and treatment

results

Manual

Adherencemeasure

Adherencemeasure

Gender

Boys59 %

Girls41 %

Age

0 %

5 %

10 %

15 %

20 %

25 %

30 %

35 %

<12 12 13 14 15 16 17

10 30 50 70 90 110 130 150 170 190 210 230 250 270 >2800

100

200

300

400

500

600

Length of treatment (days)

10 30 50 70 90 110 130 150 170 190 210 230 250 270 >2800

100

200

300

400

Length of treatment (days)

Before 2005 2005-2007

Completion rate

Completed82 %

Closed by the team4 %

Dropout8 %

Placement6 %

Therapist adherence

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1

V 01 H 01 V 02 H 02 V 03 H 03 V 04 H 04 V 05 H 05 V 06 H 06 V 07

Lives at home (completers)

93 % 97 % 89 % 85 % 83 %0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

Admission Discharge 6 mths 12 mths 18 mths

Attends school/work

26 % 88 % 82 % 80 % 80 %0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

Admission Discharge 6 mths 12 mths 18 mths

Abides the law

57 % 96 % 91 % 90 % 92 %0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

Admission Discharge 6 mths 12 mths 18 mths

Does not abuse substances

56 % 90 % 85 % 84 % 86 %0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

Admission Discharge 6 mths 12 mths 18 mths

Refrains from violence

38 % 94 % 88 % 90 % 91 %0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

Admission Discharge 6 mths 12 mths 18 mths

The MST Quality Assurance System

The MST Quality Assurance System

• Research-validated adherence technologies• Development planning for all professionals • Structured training (orientation and booster)• On-the-job training (on-going, weekly expert case review and

consultation)• Weekly clinical supervision

TherapistYouth/family

Organization

Supervisor TherapistYouth/family

Consultant

Organization

Supervisor TherapistYouth/family

ManualManual

Consultant

ManualManual

Organization

Supervisor TherapistYouth/family

TAM-R

ManualManual

Consultant

Manual

Program data and treatment

results

Manual

Adherencemeasure

Adherencemeasure

Why such an extensive Quality Assurance System?

• Target population is therapeutically challenging • Treatment model places high demands on therapists

Why such an extensive Quality Assurance System?

• Target population is therapeutically challenging • Treatment model places high demands on therapists

• Evidence based practices: Treatment results rely on adherence to the treatment model

0.60

0.72

0.83

0.95

1.07

Nu

mb

er

of

Ch

arg

es

pe

r Y

ea

r P

os

t-T

x

-0.64 -0.36 -0.09 0.19

Deviation from Mean TAM Score (TAM - .64)0 .28 .55 .83 1

Therapist adherence

High therapist adherencegives better outcomes

MST Evaluation studies in Norway(Ogden & Halliday-Boykins, 2004)

• MST teams that did not follow up on the quality assurance system, had the poorest outcomes

• High treatment adherence led to better outcomes

The MST Quality Assurance

TREATMENT RESULTSHow are the outcomes for the youths and their families?

Monitoring

MST (therapy, supervision, consultation)

Manual

MST clinical outcome study

Ogden,T. & Halliday-Boykins,C.A. (2004). Multisystemic Treatment of Antisocial Adolescents in Norway. Replication of Clinical Outcomes Outside of the U.S. Child and Adolescent Mental Health, 9, 77-83.

Ogden,T. & Hagen,K.A. (2005). Multisystemic Therapy of Serious Behaviour Problems in Youth: Sustainability of Treatment Effectiveness Two Years After Intake. Child and Adolescent Mental Health, in print.