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Young People at risk of developing ASPD:the use of multi-systemic therapy as an early
intervention within the family
Dr Simone FoxChartered Clinical & Forensic Psychologist
MST Supervisor Merton & Kingston
Dr Juliette WaitChartered Clinical Psychologist
MST Supervisor Reading
PD Congress19th November 2009
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Aims of Presentation
To think about Personality Disorder froman adolescent perspective
To develop an understanding of the risk
factors in the development of antisocialPD
An overview of MST and how it addresses
these risk factors
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Group Exercise
In pairs identify one risk and oneprotective factors for the onset ofbehavioural problems in adolescence;o Individualo Familyo Schoolo Peer groupo Community
Feedback on flipchart
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Risk & Protective FactorsContext Risk Factors Protective FactorsIndividual Low verbal skills
Favourable attitudes towards ASB Psychiatric symptomatology Cognitive bias to attribute hostile intentions to others
Intelligence Being first born Easy temperament Conventional attitudes Problem-solving skills
Family Lack of monitoring Ineffective discipline Harsh and inconsistent discipline Low warmth High conflict Parental difficulties e.g. drug abuse, psychiatric
conditions, criminality
Attachment to parents Supportive family environment Marital harmony
Peer Association with deviant peers Poor relationship skills Low association with pro-social peers
Bonding with pro-social peers
School Low achievement Dropout Low commitment to education Aspects of school e.g. weak structure & chaotic
environment
Commitment to schooling Good school-home links Good relationship with teacher(s)
Community High mobility Low community support High disorganisation Criminal subculture
Ongoing involvement in community activities Strong indigenous support network
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Common findings of 50+ years ofresearch: delinquency and drug use are
determined by multiple risk factors:o Family (low monitoring, high conflict, etc.)o Peer group (law-breaking peers, etc.)o School (dropout, low achievement, etc.)o
Community ( supports, transiency, etc.)
o Individual (low verbal and social skills, etc.)
Delinquency is a Complex Behaviour
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Causal Models of Delinquency andDrug Use
Condensed LongitudinalModel
Family
School
DelinquentPeers
DelinquentBehavior
Prior DelinquentBehavior
Low Parental MonitoringLow AffectionHigh Conflict
Low School InvolvementPoor Academic Performance Elliott, Huizinga & Ageton
(1985)
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Theoretical Assumptions
Children and adolescents live in a social
ecology of interconnected systems that impacttheir behaviors in direct and indirect ways These influences act in both directions (they
are reciprocal and bi-directional)
Based on Bronfenbrenner, Haley and Minuchin
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EcologicalModel
Child
Family
Peers
School
Neighborhood
Community/Culture
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What is MST?
Intensive, goal oriented and time limitedintervention
Community-based, family-driven
Targets the multiple causes of anti-social andcriminal behaviour in young people Highly structured clinical supervision and quality
assurance processes
Strong track record of client engagement,retention and satisfaction
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Who is the target population for MST?
Family and key participants in the environment of youngpeople
MST client is the entire ecology of the young person -family, peers, school, community
Age range 11-17 years High risk of out-of-home placement
eg. care, custody, residential school Placement risk due to their behaviour
at home / school / in the community May be involved with the criminal justice system
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What is MST? Focus is on families as the solution Focus on empowering the caregivers / parents to solve
current and future problems Parents are full collaborators in planning and delivering
interventions Assumption - Childrens behaviour is strongly influenced
by their families, friends and communities (and viceversa)
Works in partnership with a combination of systems(parents, family, peers, school and community) toaddress risk factors
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How does MST work? Assessing and understanding the factors contributing to
identified problems Having clear goals to work towards Prioritising key factors and interventions
Interventions based on techniques that have strongevidence base:
Behaviour therapy Parent management training Cognitive behavior therapy Pragmatic family therapies
Pharmacological interventions (e.g., for ADHD) Supporting the parent/carer in devising strategies to
target factors contributing to the young personsbehaviour
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How is MST implemented?
Single therapist works intensively with 4 familiesat a time
Meetings at least 2-3 times a week
Community and home based Out-of-hours service run by the team which isavailable to families 24 hours a day, 7 days aweek
Team has 3-4 therapists and clinical supervisor Involvement typically ranges from 3 to 5 months
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How is MST implemented?
Team provides the family with a single point ofcontact
MST team deliver all treatment
Typically no services are referred outside theMST team Never ending focus on engagement and
alignment with the primary caregiver and other
key stakeholders addressing barriers MST team must be able to have a lead role inclinical decision making for each case
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MST Quality Assurance System
Team comprised of range of professionals multi-disciplinary/multi-agency
Structured training orientation and regular
boosters Frequent professional development planning Weekly clinical supervision and case review Weekly consultation with consultant in USA
Research validated adherence process fortherapists and supervisor
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Whats different?
Traditional models Individual (family) Clinic-based
Fixed times High caseloads less intensive
Open-ended
Supervision
MST Ecological Home-based Flexible/24 hour Low caseloads
3x weekly + Fixed goal-driven Quality assurance
NB Not better, just different approach to address a different need
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Why does it need to be different?
Multi-determined nature of serious antisocialbehaviour
Risk factors span the ecology in which the child
is embedded Families with complex problems struggle toaccess traditional services
High costs of antisocial behaviour
incarceration, placement, victimisation Therapist adherence predicts outcome
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Video
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References
Kazdin A. E., & Weisz, J. R. (1998). Identifyingand developing empirically supported child andadolescent treatments. Journal of Consulting and
Clinical Psychology, 66, 19-36. Henggeler, S. W., Schoenwald, S. K., Borduin,C. M., Rowland, M. D., & Cunningham, P. B.(2009). Multisystemic treatment of antisocial
behaviour in children and adolescents 2ndedition. New York: Guildford Press. www.mstservices.com